Brazil Anti-Tobacco Forces Score Yet Another Victory But Work Is Not Yet Done
30th May 2018
By David J. Olson
RIO DE JANEIRO, Brazil — This country has one of the best tobacco control programs in the world, resulting in a series of laws to protect non-smokers that the Brazilian government been put into place over 20 years. During this time, cigarette smoking has fallen by more than half.
And yet smoking is still a huge problem. Almost 15 percent of adult Brazilians still smoke, according to the Ministry of Health, causing 156,000 deaths per year. Every day, second-hand smoke kills seven Brazilians.
Though smoking has fallen dramatically among both men and women, there are still 21.5 million smokers in Brazil, which puts it in the top 10 countries in terms of number of smokers. And for every success achieved by the tobacco control movement – and there have been many – the cigarette industry fights back with all of the considerable resources at its disposal.
The latest victory for the anti-tobacco forces occurred on February 1st, when the Supreme Court made a historic ruling that affirmed the authority of the Brazilian Health Regulatory Agency (ANVISA) to prohibit additives in cigarettes (including flavors like mint and cinnamon). Anti-tobacco groups believe these additives make the products more attractive to children and adolescents.
The vote was a close as it could be – a 5-5 tie. Under Brazilian law, a tie vote in the Supreme Court means the ANVISA regulation is constitutional. This ruling has made Brazil one of the first countries in the world to have a complete ban on additives.
This month I visited ACT Promoção da Saúde (ACT Health Promotion), founded in 2006, one of the organizations at the forefront of the war against tobacco at their offices here, a block from Copacabana Beach.
Anti-tobacco work began two decades ago when Dr. Vera Luiza da Costa e Silva started a movement coordinating tobacco control for the Ministry of Health’s National Cancer Institute in 25 states and helped ban tobacco advertising in mass media in 1999. Dr. da Costa e Silva is now head of the secretariat at the World Health Organization’s Framework Convention on Tobacco Control.
In 2007, ACT and its civil society allies started work to enact a national law banning smoking in public places but got strong push-back from the tobacco industry, said Daniela Guedes, ACT’s director of campaigns and mobilization. So they regrouped and decided to focus on the state of São Paulo, the largest state in Brazil (with a 2018 population of 45 million). One of their first activities was to create a sign to promote smoke-free policies at companies and restaurants.
ACT conducted a public opinion poll that showed that 88% of the population supported a smoke-free law in São Paulo state (the percentage was almost as high among smokers). Polling is an important part of ACT’s work – it helps attract the attention of the media and lawmakers.
Their initial advocacy efforts focused on then-São Paulo Governor José Serra, a former minister of health. He wanted more evidence before joining their forces, said Guedes, and anti-tobacco advocates gave it to him. Their strongest evidence was the seven people who die from second-hand smoke every day (one of the slogans of an early campaign was “He who doesn’t smoke is not obliged to smoke”). One month later, Serra proposed a ban on public smoking in São Paulo state. Despite massive resistance from the tobacco industry, the bill was passed.
This created a “cascade effect,” said Guedes, prompting many other states and municipalities to pass similar bans. And it stimulated much discussion of this issue in local and national media.
ACT and its allies then set their sights on a national smoke-free law. After much resistance from the tobacco industry, the ban was passed and signed by of then-President Dilma Rousseff in 2011. It took another three years for the law to be implemented, with the tobacco industry fighting back every step of the way. But the public smoking ban became the law of the land across Brazil.
Lately, ACT and its allies have been working against the tobacco industry’s efforts to make cigarettes seductive to children and adolescents. For example, this TV spot, makes the case against adding flavors to cigarettes and displaying them alongside of candy. On the second day it was aired, the largest Brazilian tobacco company sued ACT, asking for damages of 500,000 reales per day. The tobacco company lost and the TV campaign continued.
The number of adult smokers has decreased from 35 percent in 1989 to 15 percent in 2013, according to National Health Surveys of the Ministry of Health (scroll down to first table here). So the fight against tobacco in Brazil, despite these many triumphs, is not yet finished.
“We still have more work to do,” said Guedes. “We need to fully implement the additives ban and ban point-of-sale displays that still show cigarette packaging. This is why it is so important to pass a law mandating plain packaging – cigarette packaging is still so attractive, especially to youngsters.”
In 2015, José Serra – who by then had become a senator from São Paulo – proposed another national tobacco control bill to ban additives, advertising at point of sale, smoking in cars with children and mandate plain packaging. These steps represent the next steps in tobacco control. After three years, this bill is still going through the legislative process.
ACT is still very much engaged in the ongoing fight against tobacco but three years ago they took on another one of the risk factors of non-communicable disease – overweight and obesity. In Brazil, 25 percent of girls and 26 percent of boys are overweight, according to World Obesity.
See more details of tobacco in Brazil on the Brazil page of the 2018 Tobacco Atlas.
Obesity is Rising Almost Everywhere, Spurring A Rise in Chronic Disease
27th Apr 2018
By David J. Olson
The picture above shows the ideal, healthy plate of food for an urban adult woman in India – one cup of vegetable, one cup of rice, one and a half pieces of chapatti, one cup of protein (meat, lentil or sambar) and a half cup of yogurt.
But too often this is not the typical meal of an Indian. Some people eat too much and become overweight or obese, particularly in urban areas. Obesity increases people’s likelihood of developing diabetes, to which Indians are predisposed. Meanwhile, some people, particularly rural adolescent girls, eat too little putting themselves at risk when they become pregnant at an early age.
So Arogya World, a U.S.-based organization committed to changing the course of non-communicable diseases (NCDs) in India, created MyThali(“My Plate”), inspired by the U.S. Department of Agriculture’s “My Plate” campaign and using the guidelines from India’s National Institute of Nutrition to encourage them to make healthier choices. Arogya World is aggressively implementing this campaign in workplaces across India.
India and China continue to have the largest number of underweight people in the word, according to the Times of India, but they also have broken into the top five countries in the world in terms of obesity, The Lancet has found. This double burden of disease is becoming more common not only in India and China but also in sub-Saharan Africa and other low- and middle-income countries (LMICs). In fact, most of the world now lives in countries where overweight and obesity kill more people than underweight, according to the World Health Organization (WHO).
Worldwide obesity has tripled since 1975. In 2016, the WHO estimated that more than 1.9 billion adults – a quarter of the entire population – are overweight and 650 million of these were obese.
Obesity is becoming more common in LMICs like Ghana and Zambia as growing economies cause people to develop habits for fast food and soft drinks, become more sedentary and buy food from supermarkets rather than growing it themselves.
NCDs first achieved a global platform when the first UN High-Level Meeting on NCDs was held in 2011. In 2013, global health leaders enacted the Global Action Plan for the Prevention and Control of NCDs, 2013-2010, which had nine voluntary global targets. One of them was to “halt the rise of diabetes and obesity.”
“We’ve failed badly [in achieving that target],” said Johanna Ralston, chief executive of World Obesity, which represents professional members of the scientific, medical and research communities from over 50 regional and national obesity associations. “Things are getting worse, and obesity is growing, especially in low- and middle-income countries. Childhood obesityhas increased ten-fold in the past four decades. This represents a failure of civilization because obesity is so driven by how we live and work and move.”
Ralston says that obesity is inextricably linked to a variety of NCDs. It is a disease itself but also a major risk factor for cardiovascular disease (the leading cause of death in the world), diabetes, many cancers and other NCDs, according to the WHO. “If you don’t address obesity, you won’t address NCDs. And if you do address it, a lot of lives can be saved and health improved.”
But obesity is not just a health problem; it’s also an economic problem. “If we don’t take urgent action, the annual global medical bill for treating the diseases that follow directly from obesity is expected to reach $1.2 trillion in 2025, according to the World Obesity Day website.
The only country Ralston could think of where obesity is falling was Venezuela, which is afflicted with political crisis and food shortages, “but that’s not the way you want to solve obesity.”
Ralston also sees glimmers of hope on an otherwise bleak landscape of obesity. In 2014, Mexico imposed an 8% tax on junk foods. Recent evidence suggests that the tax has led to decreases in purchases of junk food by unhealthy people. Consumption of sugary beverages is doing down and childhood obesity is starting to plateau, she says. Last year, India levied a tax on soft drinks and flavored waters that reaches as high as 43%.
Similarly, Chile mandated packaging redesigns and labeling rules to help people make decisions about food in stores. The law prohibits the sale of junk food in school and from being advertised on TV programs or websites focused on young audiences.
Although obesity is no longer limited to rich countries, the rates of adult obesity are still higher in high-income countries of the Americas and Europe than in LMICs. In the U.K., more money is spent fighting obesity than on the police and fire services combined.
This month, The Lancet declared that “2018 must be the year for action against NCDs.” “Since 2011, and despite much exclamatory rhetoric, momentum behind efforts to mobilise action against NCDs has stalled (and that is putting it mildly),” writes The Lancet. In September 2018, the UN will have its Third High-Level Meeting on NCDs.
Public health messages about diet, calorie intake and physical activity are important but The Lancet says it is not enough. “A great disconnect remains between policy makers who issue recommendations and communities themselves that struggle with obesity — specifically, communities living in low-socioeconomic settings or suffering high levels of unemployment and social deprivation … What is sorely needed is political advocacy and action to disrupt entrenched cycles that maintain poverty and prevent ready access to healthy choices.”
But Dr. Nalini Saligram, the founder & CEO of Arogya World, the group that developed MyThali, believes that education also has an important role to play.
“I really believe we can change the way Indians think about food,” says Saligram. “Food is such a cultural thing – you feed your guests, you celebrate cultural festivals, you do so many things with food. And, in India, food is largely carbohydrates. But we can’t fight this chronic disease epidemic by wringing our hands and saying the problem is too big. We can start with something completely fundamental and, in 10 years, maybe we can make a difference.”
Facing Two Water Crises: Having Enough Water and Ensuring It’s Safe to Drink
29th Mar 2018
By David J. Olson
We talk about a world water crisis like there’s only one but there are really two. The first crisis we see playing out in Cape Town – the growing number of places that do not have enough water of any kind. The second crisis is ensuring that the water people do have is safe to drink.
The city of Cape Town has just dodged a bullet – at least for 2018. Day Zero — the day when dams levels reach 13.5% of capacity and the taps are turned off – was originally expected to take place in April, then pushed back to July. Now it has been postponed to 2019. This video shows how Capetonians are dealing with the crisis.
The three-year long drought hasn’t ended but severe water rationing has helped postpone disaster. The combined levels of dams supplying Cape Town is down to 22.7%, according to the city’s water dashboard. Capetonians have been asked to limit their water use to 50 liters (13 gallons) per person per day, and many have risen to the occasion (as a point of comparison, the average U.S. resident uses 367 liters per day, or 100 gallons).
Unfortunately, Cape Town is not an anomaly: Fourteen of the world’s megacities now experience water scarcity or drought conditions, according to Ecolab’s Water Risk Monetizer.
How can we reduce floods, droughts and water pollution? By using solutions already found in nature, things called “nature-based solutions,” like restoring forests and natural wetlands and reconnecting rivers to floodplains. That is why the theme of last week’s World Water Day was “Nature for Water,” an opportunity to explore using nature to overcome our challenges.
Under the Millennium Development Goals (MDGs), we did an excellent job of meeting half of Goal 7, Target 7.C: “Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation.” The world met the safe water target. In fact, we did it five years ahead of schedule. Between 1990 and 2015, 2.6 billion people gained access to improved drinking water sources.
“The world did great with increasing access to improved water sources under the MDGs, and now needs to make sure that water is safe to drink at the point of consumption,” said Tim Neville, who is based in Zambia for Impact Water. “And the solution to that will inevitably involve a multisector approach – government, NGOs and the private sector.”
Earlier this month, the High-Level Panel on Water — made up of 11 heads of state and a special advisor – released the report Making Every Drop Count that called for a fundamental shift in the way the world manages water. Maintaining the status quo, they found, will not get the job done.
About 36% of the world’s population live in water-scarce regions where more than 20% of the global GDP is produced, the report says. By 2050, more than half of the world’s population — and about half of global grain production – will be at risk due to water stress. Intense water scarcity may displace as many as 700 million people by 2030.
Technology will be important in solving this problem, but technical solutions alone will not be enough. We will need integrated approaches addressing technical, institutional, financial, social and environmental issues. Addressing all of these areas simultaneously will require leadership well beyond the water community, and also require political leadership.
One very tangible thing we can do – less daunting than restoring forests and wetlands – is providing safe water, sanitation and hygiene (also called WASH) at health care facilities.
John Oldfield, principal of Global Water 2020, says lack of WASH in health care facilities is “sorely unrecognized, sorely uncovered in the media and sorely undercapitalized in human, technical and financial terms. It’s really serious and it’s really solvable.”
He said the problem applies to all types of health care facilities in low- and middle-income countries – public, private and faith-based.
“Anytime a person gets sick at any level – from a huge urban government hospital down to a guy sitting under a baobab tree with a box of Band-Aids – every single one of those contexts requires access to safe drinking water, adequate sanitation facilities, hand-washing stations and waste management services. And very few of them do.”
The latest reporting coming out of University of North Carolina’s Water Institute indicates that 50% of health care facilities in Bangladesh, Haiti, Malawi, Nepal, Senegal and Tanzania lack piped water, 33% lack improved toilets, 39% lack handwashing, and only 2% have access to those three things plus waste management services.
U.N. Secretary-General António Guterres highlighted this issue at the launch of International Decade for Action on Water for Sustainable Development:
“I am using the launch of the Water Action Decade to make a global call to action for water, sanitation and hygiene in all health care facilities. A recent survey of 100,000 facilities found that more than half lack simple necessities, such as running water and soap – and they are supposed to be health care facilities. The result is more infections, prolonged hospital stays and sometimes death. We must work to prevent the spread of disease. Improved water, sanitation and hygiene in health facilities is critical to this effort.”
An important part of the solution proposed by the High-Level Panel is Universal Access to Safe Water and Sanitation. Over the last 20 years, some programs have implemented water treatment at the household or institutional level by promoting and distributing point-of-use treatment products.
PSI has implemented point-of-use water treatment programs in its social marketing programs in Africa, Asia and Latin America since the late 1990s. It now has national scale water treatment programs in more than 30 countries, and markets liquid chlorine solution and Aquatabs water purification tablets.
Impact Water, a social business, sells, installs and maintains water purification systems that use technologies like UV treatment, ultrafiltration and ceramic filters to schools in Kenya, Nigeria and Uganda. They have installed such systems in over 2,500 schools to date and plan to reach over 5,000 more in 2018 alone.
Palladium manages social marketing programs in Mali, where it markets Aquatabs, and Zambia, where it distributes two brands of water purification solution, Klori-Safe and Klori-Pure. In 2017, Palladium sold over 7.5 million Aquatabs tablets in Mali, enough to purify 150 million liters of water.
These are only three examples of point-of-use water treatment. Taking safe water to the next level will require all of this and a whole lot more.
“To ensure water is microbiologically safe to drink, point-of-use treatment technologies need to be in place and this is a massive endeavor,” said Neville. “One way is to have more, low-cost, effective institutional and household technologies made available but unless they are user-friendly and often aspirational they won’t yield sufficient uptake and consistent use.”
Mental Health Still Grossly Underfunded but There Are Glimmers of Hope
28th Feb 2018
By David J. Olson
The problem with mental health and substance abuse in Africa and other developing countries is not that awareness has not been raised about these huge contributors to the global burden of disability.
Annually since 2009, the World Health Organization (WHO) Mental Health Gap Action Programme has been meeting to scale up services for mental, neurological and substance use disorders.
In 2013, the World Health Assembly adopted the WHO’s Mental Health Action Plan 2013-2020, which is designed to provide guidance for national action plans in all resource settings.
And most notably in 2015, world leaders recognized the importance of mental health and substance abuse in the newly minted Sustainable Development Goals. Within Goal 3 (the health goal) of the 17 SDGs, there is a target for mental health and another target for substance abuse. Here are the Goal 3 targets.
So mental health has finally been given a hard-fought and much-deserved seat at the global health table. It just has not been given much money or resources.
As this WHO infographic shows, only 1 percent of the global health workforce works in mental health and the median public expenditure on mental health per person is only $2 in low- and lower-middle income countries. This paper asserts that the amount of development assistance for health is “paltry,” with less than 1 percent specifically earmarked for people with mental disorders.
“Sadly, I don’t see that the funding gap for mental health has changed much from the recent past,” said Sean Mayberry, founder and executive director of StrongMinds, a non-profit organization that treats African women with depression through group talk therapy led by community workers. “The World Bank and WHO made declarations about prioritizing global mental health in 2016 but they did not put any money against it, so we are still in the same spot.”
Yet Mayberry also sees glimmers of hope that resources may be in the early stages of catching up with the rhetoric. He notes that his own team has raised almost $5 million since 2014 thanks to a stable of very forward-looking foundations who believe treating mental health in Africa is a smart investment.
StrongMinds’ own efforts have resulted in more than 25,000 Ugandan women treated for depression with 75% of them depression-free at the end of treatment and 72% depression-free six months after treatment. This was done by cost-effective group talk therapy conducted by trained community health workers.
“Most donors don’t fund mental health because they think mental health interventions are costly and take a long time to yield results,” said Mayberry. “These interventions are working and more would be reached if more donors were willing to consider them.”
In Liberia, the Carter Center has trained 230 clinicians in mental health, with 64 specializing in the needs of children and adolescents, said Janice Cooper project lead for the Liberia Mental Health Program. These graduates will provide mental health and psychosocial care in schools, clinics and other youth settings.
The Carter Center also fights against mental health stigma in Liberia by focusing on mental health service users and their families, religious and traditional leaders, journalists, health care workers, and trains law enforcement officers in crisis intervention – an evidence-based intervention also used by law enforcement in the U.S., said Cooper.
The Carter Center says Liberia is “on course to expand mental health care to 70 percent of its population within the next few years.”
The Bill & Melinda Gates Foundation, which has long ignored non-communicable diseases (NCDs), including mental health (see first question here), has just put out a call for funding in its Global Grand Challenges to promote “Strong Minds for Stronger Adolescent and Young Mothers,” the first of its kind that mental health advocates can recall.
A new initiative called citiesRISE brings together international and national leaders in mental health to drive a new level of progress through its networks, experience and expertise at previously unattainable scale. citiesRISE has started working to develop a variety of community-based models and new strategies in Bogota, Chennai, Nairobi, Seattle and Singapore, and is looking for more cities.
In 2014, the Mental Health Atlas, published by WHO, reported very mixed progress in mental health in Africa since its last atlas in 2011:
- There was an increase of 34 percent in the number of psychiatrists in the Africa region and 27% in the Southeast Asia region (which includes Bangladesh, India and Indonesia), although these increases are from abysmally low bases.
- However, the number of nurses working in mental health in these two regions fell by 8 and 6 percent respectively.
- In the Africa region, the number of mental hospital beds fell by 15%, the same drop as with general hospital beds. In the Southeast Asia region, there were increases in both categories.
- The number of admissions to mental hospitals and psychiatric wards of general hospitals increased by 13% in the Africa region and 26% in Southeast Asia region
Mental health legislation is a key component of good mental health system governance, and 63 percent of those countries that responded to the 2014 Mental Health Atlas said they had a stand-alone law for mental health (the rate was 55% in Africa and 60% in Southeast Asia).
Perhaps the most recent country to enact a stand-alone mental health law is Liberia, where former President Ellen Johnson Sirleaf signed the bill, which will protect people living with mental health disorders from discrimination and will give access to quality mental health care in all 15 counties, before she left office last month.
It wasn’t that long ago that NCDs got almost no attention at the global level. Yet in September, the United Nations General Assembly will stage its third high-level meeting on the prevention and control of NCDs – although much of this focuses on the more high profile NCDs, like heart and lung disease, cancers and diabetes. Let’s hope that with this event, and others like it, the resources soon start to catch up with the rhetoric.
Global Contraceptive Use Rising but More Progress Needed to Reach Target
30th Jan 2018
By David J. Olson
By July 2017, more than 309 million women and girls were using modern contraception in 69 focus countries identified by Family Planning 2020 (FP2020), a movement created in 2012 by four core partners, 38.8 million more than in 2012.
This information came out in FP2020’s annual report “The Way Ahead, 2016-2017,” released in December. It reported that use of modern contraception in these 69 countries from July 2016-July 2017 prevented 84 million unintended pregnancies, 26 million unsafe abortions and 125,000 maternal deaths. This is all great news.
It came with some less-than-great news. FP 2020 has set the goal of reaching 120 million new users in the eight years between 2012 and 2020 – or 15 million every year. By that measure, we should have reached 75 million new users by mid-2017, and 38.8 million is only 52% of that.
Clearly, we have a lot more work to do to reach the 120 million target.
One of the things that can help us make more progress towards is new and renewed commitments. At the 2017 Family Planning Summit in London, 75 commitment-makers stepped forward with commitments – including 25 partners making commitments for the first time.
Beth Schlachter, executive director of FP2020, says the 120 million target is still relevant, though unlikely to be met by 2020. But she said that “we are an estimated 30 percent over the progress level that would have happened had there not been the FP2020 partnership.”
Schlachter says the S-Curve pattern of modern contraceptive growth presented in the report is a good way to spot opportunities for future growth. The S-Curve divides the 69 countries between 15 countries with “high prevalence and growth slowing and leveling off,” 13 countries with “low prevalence and slow growth” and 41 countries where rapid growth can occur. It is in these 41 countries – half of which are in sub-Saharan Africa – where rapid growth is likely to occur which can propel us to the 120 million target.
But the international family planning community also faces new challenges.
A Kaiser Family Foundation report released in December found that donor government funding for family planning fell in 2016 for the second year in a row, dropping from $1.34 billion in 2015 to $1.19 billion in 2016. Much of this decrease was due to exchange rate fluctuations and the timing of donor disbursements but 22 percent of it came from actual cuts in funding from donor countries including the U.S. and the U.K., the two largest donors.
Related challenges have come from the Trump Administration —the re-imposition of the Global Gag Rule, or the Mexico City Policy, trying to cut U.S. funding for family planning to zero and cuts in support for the U.N. Population Fund (UNFPA).
However, congressional appropriators ignored Trump’s request to zero out international family planning and reproductive health (FP/RH) programs in his proposed Fiscal Year (FY) 2018 budget request and so the U.S. government is still operating at FY 2017 levels requested by the Obama Administration and signed by the Trump Administration, according to Craig Lasher, senior fellow at Population Action International. The House of Representatives has appropriated $461 million and the Senate $622.5 million for FP/RH for FY 2018 but those amounts will have to be reconciled in a final budget bill (the FY 2017 appropriated level for FP/RH was $607.5 million).
In the meantime, says Lasher, there have been a growing number of reports of funding shortfalls at the field level in some countries across health and development sectors.
The reinstatement and expansion of the Global Gag Rule, which occurred on Jan. 23, 2017, is starting to make its impact known. One organization that has been particularly hard hit is Marie Stopes International, which estimates that 2 million women it would otherwise have served will be denied sexual and reproductive health services as a result of the order. Poor communities in Madagascar, Zimbabwe and Uganda are already feeling the effects of the expanded policy. The International Planned Parenthood Federation says that it stands to lose $100 million and that its member organizations are feeling the impact in 29 countries.
The significant contribution of social marketing should also be highlighted. In 2017, the social marketing organization DKT International released its annual report on contraceptive social marketing statistics showing that 97 contraceptive social marketing programs in 59 countries delivered 74.9 million couple years of protection (CYPs) in 2016. This is 9.4 million CYPs more than the 65.5 million CYPs generated in 2012, when FP2020 was launched.
DKT President & CEO Chris Purdy says that the focus should be on stimulating demand for modern contraception. “I continue to believe that the emphasis needs to be on education and behavior change,” he said. “The supply chain will rise to meet demand, but investments to increase uptake among women and men are needed.”
Schlachter says the key to reaching 120 million is better alignment of resources and working together to shape ambitious and achievable programs at the country level and getting partners to unite behind them.
This FP2020 press release summarizes the report.
For Global Health, 2017 Was a Year of Progress, Near Triumphs and Threats
2nd Jan 2018
By David J. Olson
In looking back over my last 12 blog posts here at Global Health TV, it is clear that 2017 was a year of progress, near triumphs and threats to global health.
In September, I reported that great progress has been made against diseases and health conditions that kill us (like respiratory infections, diarrhea, neonatal preterm deaths and communicable diseases like AIDS and malaria) while new threats had emerged that are generally less fatal — things like obesity and mental illness.
In particular, we have made progress against communicable diseases but now face a rising tide of non-communicable diseases (NCDs) like cancer, diabetes, hypertension and cardiovascular diseases, as I wrote at the beginning of 2017. Cancer is growing almost everywhere in the world. For example, cervical cancer causes over 500,000 new cases every year, even though vaccination, early screening and treatment of precancerous lesions can prevent most cases.
Fortunately, more and more pharmaceutical companies are trying to address both communicable and non-communicable diseases with innovative access-to-medicine initiatives, and organizations like the Access to Medicine Index are keeping them honest. I also learned that many access-to-medicine initiatives are poorly evaluated (or not evaluated at all) and need to do a better job of measuring the impact (or lack thereof) of such initiatives.
After many years of annual increases in funding for global health and development, global health progress came under threat in 2017 with the administrations of Donald Trump in the U.S. and Theresa May in the U.K.
In May, Trump released his Fiscal Year 2018 budget request to Congress that includes $2.5 billion in cuts to global health. At year’s end, the fate of such cuts is still unclear, although they have plenty of opposition in the U.S. Congress, both by Republicans and Democrats. The Kaiser Family Foundation predicts dire consequences if such cuts are retained.
In the UK, Penny Mordaunt, the Brexit-backing disabilities minister, was appointed international development secretary to replace Priti Patel who resigned in November under pressure after holding unauthorized meetings with Israeli officials. Mordaunt has said that she will place discrimination against disabled people at the heart of her development strategy but hasn’t said if she will recommit to having 0.7% of national income spent on international development.
The near triumphs of 2017 are that we are still close to eliminating both polio (17 cases the week of Dec. 13) and Guinea worm (26 cases) but it did not happen in 2017. Maybe 2018.
The fight against trachoma, the world’s leading infectious cause of blindness, continues but we are a little further away from elimination than we are with polio and Guinea worm. Trachoma continues to plague about 50 countries where 192 million people are at risk, according to the Carter Center, which has set a goal of eliminating it by 2020 in Mali, Niger, Sudan, Uganda and the Amhara Region of Ethiopia where it has programs. Several other countries may also achieve elimination by 2020.
My first blog of 2018 will be about how more women and girls have access to modern contraception than ever before. This month, FP2020 released its annual report showing that 309 million women and girls are now using modern contraception in 69 FP2020 focus countries. I told this story from Mexico where I met an NGO that has changed the way it promotes contraceptives to young people by being less preachy and more fun.
A report released in 2017 told of the appalling increase in violence perpetrated against health workers and facilities. The extent and intensity of such violence “remained alarmingly high,” said the report, which found that accountability for committing such attacked remains inadequate or non-existent. The report blamed the United Nations for failing to follow through on its own recommendations for preventing attacks and ensuring accountability for those who commit them.
In an extreme form of task shifting, I recounted the story of American surgeon Dilan Ellegala who went to Africa to do brain surgery and ended up teaching lower level health cadres how to do it, an approach he calls “train-forward,” as recounted in the book “A Surgeon in the Village: An American Doctor Teaches Brain Surgery in Africa.” The book highlighted the larger problem of a lack of surgeons in low- and middle-income countries.
And to end on a happy note, I was delighted to tell the story of Suelen, a black Brazilian woman who fought her way out of extreme poverty and now has a thriving food truck business and is going to law school so that she can defend the rights of other black women who are being oppressed. What’s the link with global health? She got on the track to success after her infant daughter came down with pneumonia and asthma and found treatment in a child health program run by Saúde Criança (Child Health). That’s a good place to end 2017.
Polio Vaccine Switchover: An Untold Success Story In Global Public Health
28th Nov 2017
By David J. Olson
In April 2016, something extraordinary happened in global health. Thousands of community health workers in more than 120 countries — from African villages to the Himalayas to the Pacific Islands — all mobilized and synchronized their efforts to switch from one oral polio vaccine to another. Any slip-ups could have resulted in creating more “vaccine-derived” poliovirus cases at a moment when we are down to our last few cases of polio.
The fact that many children receiving such oral vaccines were living in areas of high conflict and low development (which means low levels of health infrastructure) made the accomplishment all the more remarkable.
The feat was accomplished in a single day (each country was told to pick one day within a two-week period in April 2016 to make the change).
The story of this amazing synchronized switch constitutes an untold global health success story and can be told with the backdrop of the current number of wild poliovirus type 1 cases down to only 15 — 10 in Afghanistan and 5 in Pakistan. The polio eradication community had hoped that we would be down to zero by 2017. Now they are hoping it will happen in 2018.
“It was a great achievement, especially when you understand the scope, because it happened in more than 120 countries,” said Joël Calmet, senior director of communication for polio of Sanofi Pasteur, a pharmaceutical company which produces 500 million polio vaccines annually. “I was surprised by two things – the fact that it went well almost everywhere and the fact that no poliovirus type 2 has been detected following the removal of the outdated trivalent oral vaccine.”
The Polio Eradication and Endgame Strategic Plan 2013-2018, approved by the World Health Organization (WHO) in 2013, calls for the removal of all oral polio vaccines (OPVs) by 2019-2020, including the trivalent OPV (which protects against three strains of poliovirus) that was replaced in April 2016 and the bivalent OPV (which protects against two strains) now being used.
Eventually, the bivalent OPV will be replaced by an injectable polio vaccine. Until polio is eradicated, using both injectable and oral vaccines provide the best form of protection, according to the Polio Global Eradication Initiative. But by 2019-2010, the plan is to use only the injectable vaccine.
The obsolete trivalent OPV contained all three poliovirus serotypes (1, 2 and 3) and led to the eradication of wild poliovirus 2 in 1999. The last detected case of wild polio virus 3 was in 2012. Now we are down to the last 15 cases of wild poliovirus 1 and those last few cases are proving the most difficult to eliminate. Even after wild poliovirus 1 is “eliminated,” three more years will be required before WHO can verify that it has been “eradicated.”
When that happens, it will be only the second human disease ever eradicated, after smallpox, which was declared eradicated in 1980. Guinea worm is also close to eradication with the Carter Center reporting only 26 cases reported in 2017 in Chad and Ethiopia.
There are also 80 cases of circulating vaccine-derived polio virus cases – 70 in Syria and 10 in the Democratic Republic of Congo – but these are believed by WHO to be “ancient strains” and not related to the switchover in OPVs, according to Calmet.
Frank Conlon, director of the Core Group Polio Project, recalls the destruction of the poliovirus type 2 in Kenya. “I was one of the honored guests last year at the Kenya Medical Research Institute laboratory to witness the destruction of their final stocks of Type 2 poliovirus that were contained in the laboratory. It was a big event for Kenya, and it was widely attended by the press.”
The Bill & Melinda Gates Foundation, which has been a key player in the polio eradication effort, is now looking into the future to see how lessons learned from polio eradication can be be applied to other diseases. To that end, the Foundation has just awarded the Johns Hopkins Bloomberg School of Public Health with a $3.7 million grant “to capture the lessons learned from polio eradication and prevent this knowledge from being lost, so that systems and strategies can be repurposed, not recreated.”
Suelen and Her Family: A Brazil Child Health Success Story
31st Oct 2017
By David J. Olson
NOVA IGUAÇU, Rio de Janeiro State, Brazil — In 2012, Suelen hit rock bottom. She was living in extreme poverty with her husband and young son in a dilapidated house with a roof that was leaking water. While she was pregnant with her second child, her husband left her. When that child, Ana Luiza, was born, she was sick with pneumonia and asthma.
Suelen was at her wit’s end. Every day was a struggle. She made a living selling empanadas out of a canvas tent here in this city of 800,000 about 40 minutes from downtown Rio de Janeiro. “I was working all the time every day just to pay for food for the next day,” said Suelen. “I didn’t think about the future, just how I was going to eat tomorrow.”
Today, the situation of the family is the reverse of what it was five years ago. The health and wealth of the family is thriving. They have a highly successful food truck (that is expanding to home delivery). The children are going to good schools. And Suelen is going to law school so she can defend the rights of other black women who are being oppressed.
The moment when it all turned around for Suelen was during one of her daughter’s visits to Lagoa Federal Hospital in Rio, when she came into contact with Associação Saúde Crianća (Child Health Association), a social organization that has improved the lives of 70,000 people in the poorest families in Brazil since it was founded in 1991. It has been named one of the best NGOs in Brazil, and one of the 500 best NGOs in the world.
Through 12 hospitals in Brazil, Saùde Criança identifies unhealthy children and their families living below the poverty line. They are interviewed and assessed. Based on this information, a family action plan is developed with objectives and indicators in five major areas – health, citizenship, housing, education and family income. The program offers direct assistance, technical support, professional training and citizenship support (with lawyers assisting with issues such as obtaining identity cards, divorces, government benefits, etc.).
Every month, the mothers come to Saùde Criança’s offices for evaluations to check on the progress of the families against their plans. Saùde Criança assists the families for around two years, the amount of time deemed necessary to solve the families’ major problems and to set them on a sustainable path. Sometimes, such as in the case of Suelen, more time is needed.
Saùde Criança has diversified funding that doesn’t permit it to become too dependent on one or two donors. About 54 percent of its funding comes from Brazilian and international companies such as Praxair Foundation, Johnson & Johnson and Repsol Sinopec Brasil as well as social entrepreneur organizations like Ashoka, the Skoll Foundation and Schwab Foundation for Social Entrepreneurship. The other 46 percent comes from individual donations.
That encounter at Lagoa Hospital changed everything for Suelen and her family. Her husband Ricardo came back and has become an important part of the family. Ana Luiza’s health problems have been stabilized.
The family’s desperate financial situation has turned around. Suelen took Saúde Criança’s cooking course and bought a trailer, which she used to sell her food close to home. Later, with the help of Saúde Criança, she upgraded to a food truck. Recently, Suelen and Ricardo bought a motorcycle to initiate home food deliveries. She benefited from training in bookkeeping and marketing.
Saúde Criança’s housing program repaired the leaking roof, which was contributing to Ana Luiza’s poor health. With help from the family and their relatives, a second floor was added with one bedroom for the parents and one for the children (previously, the parents had been sleeping in the living room, with the children next to them on a mattress on the floor).
“The most important thing to me is that my daughter’s health has stabilized,” says Suelen. “Today I can live and stand on my own two feet, because Ana made it.”
They now have a beautiful house and appear to have arrived in the middle class. But when I asked them if they feel middle class, they laughed and said “No, we want to accomplish more.” They have escaped extreme poverty, they say, but are still poor. For one thing, they want to own their own home.
Suelen and Ana Luiza graduated from Saúde Crianca earlier this year so the family is now on their own. Ana Luiza attends the Instituto Nacional Santo Antônio, one of the best schools in Nova Iguaçu, where she has a 100% scholarship.
Even though the food truck is a huge success and provides a good income for the family, Suelen wanted more. So she applied, and was accepted, into law school, with a 70% scholarship.
“Much of my motivation comes from the fact that as a black woman in Brazil, I have been suffering from prejudice all of my life,” she says. “And I have seen black friends suffering prejudice and who fought back, because they had the knowledge. I wanted to do this, too, because I am a black woman with black children and I want a better world for them.”
Though the family is prospering, their new lifestyle demands a lot of Suelen and Ricardo. They have to get up early to get the children off to school. Then they are preparing the food truck and operating it from early evening until early in the morning. They get to bed at 3 am, and then get up and start all over again. Suelen goes to law school four days a week.
Luis Ricardo, the 10-year-old son, says that other people can’t believe how hard they all work to achieve their new-found success. They tell him their family are brave fighters.
Dramatic Global Health Improvements Save Lives But New Threats Emerge
26th Sep 2017
By David J. Olson
Over the last decade, we’ve made great progress against diseases and health conditions that can kill people, especially children under 5, but because of political and budget challenges, we risk backsliding on those gains. And we’re facing a tsunami from health issues that do not always kills us – namely, obesity, conflict and mental illness – but cause poor health.
Those are my take-aways from two major reports that came out this month, one tracking how we are doing against the Sustainability Development Goals, particularly in global health, and the other a scientific study focused solely on global health.
“Goalkeepers: The Stories Behind the Data 2017,” a report from the Bill & Melinda Gates Foundation, was aimed at last week’s United Nations General Assembly. To draw attention to the report, the Gateses held a high-profile event featuring former President Barack Obama. The report touts the many global health advances that have been made but also cautions about the risks of complacency.
The Goalkeepers report plans to track 18 data points in the Sustainability Development Goals every year until 2030. The Gateses say their goal is “to accelerate progress by diagnosing urgent problems, identifying solutions, measuring results and spreading best practices.”
“Candidly, we are unlikely to reach every target – some are more realistic and some are more aspirational – but that doesn’t absolve us of the responsibility to get as close as we can,” write the Gateses.
The other report, the annual Global Burden of Disease (GBD) Study 2016, found that substantial progress has been made in driving down death rates from diseases and health conditions like lower respiratory infections, diarrhea, neonatal preterm birth, HIV/AIDS and malaria, which all declined by 30% or more in just ten years, according to the Institute for Health Metrics and Evaluation (IHME) which coordinated this year’s study.
“Death is a powerful motivator, both for individuals and for countries, to address diseases that have been killing us at high rates,” said Dr. Christopher Murray, IHME director. “But, we’ve been much less motivated to address issues leading to illnesses. A triad of troubles – obesity, conflict, and mental illness, including substance use disorders – poses a stubborn and persistent barrier to active and vigorous lifestyles.”
The Gateses highlight excellent global health and development news in Gatekeepers:
- The number of people living in extreme poverty (less than US $1.90/day) has declined from 35% in 1990 to 9% in 2016, with many of these decreases in China and India.
- After peaking in 2005, global HIV deaths per 1,000 people dropped dramatically from 0.3 deaths per 1,000 people to 0.14.
- The number of children under 5 dying dropped from 11.2 million in 1990 to 5 million in 2016.
- 300 million women now have access to contraception
The fight against HIV is increasingly seen as a global health success story. “2005 was when the world made the commitment to get low-cost drugs out to as many people as possible and something wondrous took place,” Bill Gates said at the event with Barack Obama. “The number of AIDS deaths came down dramatically. We had funding, we had commitments, we had people thinking about how to get those drugs out there. But now there really is a risk that the death rate could go back up. So we are challenged to maintain the funding.”
Child health is another bright spot. In 2016, for the first time in modern history, fewer than 5 million children under age 5 died in one year. Researchers attribute this accomplishment to a variety of factors – improvements in education of mothers, rising per capita incomes, declining fertility, increased vaccination, mass distribution of insecticide-treated bed nets, improved water and sanitation and other factors. But if we regress, says the report, we will lose an additional 800,000 children under 5 per year by 2030.
The “triad of trouble” cited in the GBD Study 2016 points to the growing and pernicious effects of non-communicable diseases (NCDs) in developing countries.
- Obesity: The rate of illness related to people weighing too much is rising quickly. High body mass index is the fourth contributor to the loss of health life (after high blood pressure, smoking and high blood sugar).
- Conflict: Deaths over the past decade due to conflict and terrorism have more than doubled. Last week at the UN General Assembly, Secretary-General Antonio Guterres and World Bank President Jim Yong Kim launched a report calling for greater political and financial commitments to prevent conflict. The bank and the U.N. are focusing on mitigating famine conditions in South Sudan, Yemen, Somalia and Nigeria.
- Mental illness and substance abuse: These disorders continue to contribute to the loss of healthy life in 2016, affecting both rich and poor countries. Treatment rates remain low and even in rich countries, prevalence of the most common disorders has not changed.
The study found much other evidence on the growing impact of NCDs including the fact that NCDs were responsible for 72% of all deaths worldwide in 2016, as compared to only 58% in 1990.
Initiatives to Expand Access to Medicine on the Rise, But Need Better Evaluation
31st Aug 2017
By David J. Olson
In the 1990s and 2000s, AIDS activists and other global health advocates started pressuring pharmaceutical companies to share their largesse with low- and middle-income countries (LMICs) by supplying critical medicines for free or at subsidized prices, especially for HIV/AIDS. The pressure was successful, and led to a series of access-to-medicine (AtM) initiatives.
The international community increasingly recognizes that the pharmaceutical industry must play a leading role in improving access to medicines. And apparently pharma companies themselves also acknowledge this responsibility, according to a study published in Health Affairs by a team of researchers at Boston University Department of Global Health. That study found that the number of these initiatives grew from 17 in 2000 to 102 in 2015. The researchers called this “clear evidence” that pharmaceutical companies had responded to calls to increase their commitment to improving access to medicines.
The industry’s role was first articulated when the Millennium Development Goals (MDGs) were drafted in 2015. Goal 8, Target 8E read: “In cooperation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries.”
The Sustainability Development Goals, which replaced the MDGs in 2016, further enshrined that idea in Goal 3.8 which aims to “achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”
The Health Affairs study identified 385 health initiatives across 21 companies. Of these, 120 were categorized as AtM initiatives. Novartis was first with 14 initiatives, Sanofi was second with 13 and Roche was third with 10 (21 were multi-company partnerships).
Eighty-eight percent of these initiatives focused on infectious disease (including HIV and neglected tropical diseases), 52 percent addressed non-communicable disease and 33 percent focused on maternal and child health (some initiatives focused on multiple health areas).
The Access to Medicine Foundation, funded by the Bill & Melinda Gates Foundation and the UK and Dutch governments, compiles an index on the progress made by pharma companies to make their medicines accessible. Every two years since 2008, the Foundation has published the Access to Medicine Index. In 2016, Glaxo Smith Kline, Johnson & Johnson and Novartis were named as the leading companies.
The Health Affairs article says the index has created an incentive for expanding AtM initiatives, as well as for more transparent reporting. But it also says that the index’s ranking methodology does not include a rigorous review of the evidence and should be improved to hold companies more accountable.
The Boston University researchers found that few of these initiatives evaluate their activities well. Of the 102 AtM initiatives identified, the researchers found published evaluations for only seven. From those seven, the researchers found 47 articles that met their inclusion criteria but determined that 62 percent of these were low quality, 32 percent were very low quality and 6 percent were moderate quality. None of them were rated high quality.
“Overall, our findings suggest that current efforts to evaluate the impact of industry-led access-to-medicines initiatives are inadequate,” they write.
Boston University is now monitoring and evaluating an AtM initiative in Kenya to address these concerns. The initiative, called Novartis Access, seeks to provide 15 medicines to address breast cancer, cardiovascular disease, type 2 diabetes and respiratory illnesses at a cost of USD $1 per treatment per month. The project started in Kenya in 2015 and plans to expand to 30 countries in coming years. Novartis Access hopes to reach 20 million people per year by 2020.
From the beginning, Novartis Access sought the help of Boston University to evaluate its impact and the prices of these medicines at health facilities and households in Kenya in an objective and transparent manner. Novartis has no control over the evaluation process and Boston University publishes protocols, agreements and all the results on this website.
“One things we know about programs offering low-priced products – not just medicines but also food or fuel – is that it’s often not the poorest people who benefit, but the middle-income groups who know how to access the medicines and appropriate treatment,” said Richard Laing, a professor at Boston University who is involved in the evaluation. “For that reason, we’re very keen to find out what happens at the household level, particularly to the poorest families.”
Laing said this evaluation is different because past efforts to measure the impact of AtM programs have almost always occurred after the fact: “The problem with these evaluations is that you don’t know what the situation was like before, and there is often no control group, so the evaluations have tended to be weak even when the best interventions have take place.”
The Access to Medicine Foundation welcomes additional efforts to evaluate the impact of access to medicine programs, said Danny Edwards, research program manager for the foundation.
“We’ve noticed an increasing orientation of companies in this direction over recent years, from University College London’s independent evaluation of Novo Nordisk’s Base of the Pyramid Program, to Novartis Access, to the explicit commitment of companies participating in Access Accelerated to evaluate and share the impact of the work taking place under that umbrella, which includes Boston University, Union of International Cancer Control and the World Bank.”
Teaching Surgery in Africa: Compelling Book Reveals Neglected Area of Health
3rd Aug 2017
By David J. Olson
“In early 2010 Bill Hawkins, then executive editor of the Post and Courier in Charleston, South Carolina, told me, ‘I met this crazy brain surgeon who opened a guy’s head with a wire saw in Africa. Check him out. Maybe we’ll send you to Tanzania.’ Not many reporters get such an invitation, but thanks to Bill, I was soon on my way.’”
So writes Tony Bartelme in “A Surgeon in the Village: An American Doctor Teaches Brain Surgery in Africa,” an informative and highly engaging book about a neglected area of global health – the dearth of surgeons in low- and middle-income countries. The book, published in March, is based on hundreds of hours of interviews that the author conducted in the U.S. and during five trips to Tanzania between 2010 and 2015.
When I started reading this book, I approached it as an obligation – something I had to do to inform myself, and possibly my readers, about an area of global health I knew nothing about.
But to my great surprise, I not only found it informative, I enjoyed it. The book is written in short chapters and in more of a novelistic style than most pieces of non-fiction. What I thought would be a chore turned into a pleasure. Perhaps that is because Bartelme is an experienced journalist who knows how to tell a good yarn.
Bartelme tells the story of Dilan Ellegala, a Sri Lankan-born American, who ignores his father’s advice to become a family doctor (“You should have a life”) and becomes a brain surgeon because he had fallen in love with the brain (in medical school, he kept a brain in a glass jar in his room so he could pull it out, hold it up to the light and study it).
He goes to Haydom Lutheran Hospital in a remote, rural part of Tanzania for six months of medical sabbatical. He finds out that Tanzania, a country of 42 million people, has just three brain surgeons in the country, all of them in Dar es Salaam.
One day a farmer came to the hospital, who had bashed his head in a fall. He was in serious condition but Ellegala knew he could save him if he could get inside the man’s head to stop the bleeding. But he had no way of opening his skull due to a lack of a Gigli saw (which goes for twenty bucks in the United States).
He told himself that the farmer was going to die. “Nothing I can do. Let it go,” he told himself. So he went for a run in the bush to clear his mind and encountered a man cutting a tree limb with a wire saw. He bought the saw off the man, rushed back to the hospital and saved the man’s life.
Ellegala quickly realizes that despite the well-intentioned efforts of rich country doctors who travel to developing countries on short-term assignments, this approach will never address the underlying problem in these countries – the lack of surgeons.
Apart from a small number of global health leaders, Bartelme writes, there was no public outcry over the shortage of surgeons at the time: “None of the U.N. Millennium Development Goals mentioned the shortage of surgeons and other skilled health care workers. The United Nations’ 356-page update in 2005 didn’t use the words surgery or surgeons once.”
Yet 17 million people die every year because of the shortage of surgeons, more than AIDS, malaria and tuberculosis combined. In 2006, Haile Debas, the director of the University of California Global Health Institute, and some colleagues published a study that showed 11 percent of the world’s global burden of diseases could be averted or treated with surgery.
In 2015, the Lancet Commission on Global Surgery produced the report Global Surgery 2030, with five key messages:
- 1.5 billion people lack access to safe affordable surgical and anesthesia care.
- 143 million additional surgical procedures are needed each year to save lives and prevent disability.
- 33 million individuals face catastrophic health expenditure due to payment for surgery and anesthesia each year.
- Investment in surgical and anesthesia services is affordable, saves lives and promotes economic growth.
- Surgery is an indivisible, indispensable part of health care.
The Commission found that 5 billion people worldwide are unable to reach surgical services, and over half the global population cannot access the treatment they need should they, for example, hemorrhage after childbirth, suffer a burn or develop cancer. And access to care is even worse for those in low- and middle-income countries.
Ellegala came to believe that the only way to solve this problem in a sustainable way was to use Western surgeons not to do the surgery, but to teach Tanzanians to do it themselves – and not doctors – who are also in short supply — but lower level health cadres. He calls this approach “train-forward.” That is what Ellegala does with Emmanuel Mayegga, an assistant medical officer, who had never done any kind of surgery before, let alone brain surgery. But it works, and Mayegga becomes a credible brain surgeon.
Before Ellegala returns to the U.S., he tells Mayegga he must teach someone else brain surgery. So he trains Emmanuel Nuwas who, in turn, trains another. “Train-forward” in action.
Eventually, Ellegala, his wife Carin Hoek, a pediatrician from the Netherlands, and others create Madaktari Africa (Madaktari means “doctors” in Swahili) ”) — a group that sends hundreds of doctors around the world to serve as mentors and to create a sustainable new model for global health. Madaktari’s story is told here.
“A Surgeon in the Village” is an excellent read, even to non-global health aficionados, and sheds much-needed light on a neglected area of global health.
Budget Debates in US, UK Could Augur Poorly for Global Health Funding
25th Jul 2017
By David J. Olson
Global health financing has not been in such jeopardy since the large investments in it started in 1991 – the year in which global health funding started an upward trajectory that moved higher in all but three years.
In particular, the rise of Donald Trump of the United States and Theresa May of the United Kingdom —the leaders of the two largest donor nations — have raised concerns about the prospects for development assistance broadly, and global health specifically.
In 2016, development assistance for health (DAH) reached $37.6 billion, eking out a miniscule 0.1% increase from 2015 that followed a pattern of little growth since 2010 (DAH grew 11.4% annually from 2000 to 2010 but only 1.8% since 2010), according to “Financing Global Health 2016,” published by the Institute for Health Metrics and Evaluation in April. DAH peaked at $38 billion in 2013, dropped to $36 billion in 2014 and has recovered slightly in the two subsequent years. This infographic provides a snapshot.
The U.S. and the U.K. have been the two top contributors to DAH but both countries have political environments that have called into question their future commitments to foreign aid and global health.
Trump’s 2018 budget request to Congress contains unprecedented cuts (more than $2 billion) to global health. If those cuts are enacted, writes the Kaiser Family Foundation, they will bring funding below 2008 levels. Family planning support would be eliminated. Kaiser predicts the cuts could result in the following scenarios starting in 2018:
- Additional new HIV infections between 49,100 to 198,700;
- Women and couples receiving contraceptives would decline from 6.5 million to almost 25 million; and
- Additional abortions between 819,000 and more than 3 million.
More than half of the $2 billion in cuts to global health would come from international HIV/AIDS programs. In a new paper, the Center for Strategic and International Studies says the cuts would jeopardize U.S. leadership on HIV/AIDS and “raise the possibility that the pandemic will reignite, threatening U.S. and global health security.”
However, in the U.S. political system, Congress has the last word on the budget, and even Republican senators say these cuts will not stand. But however the final budget turns out, it could still perpetuate the recent stagnation in global health financing.
A series of hearings earlier this month featuring Secretary of State Rex Tillerson and U.S. Agency for International Development Administrator-designate Mark Green revealed how the Trump Administration is of two minds about foreign aid.
Tillerson testified at four hearings on the proposed budget cuts. Republicans and Democrats alike lambasted the proposed cuts. Sen. Lindsay Graham, the Republican chairman of the Senate subcommittee that oversees foreign aid, said these cuts would put lives at risk. Tillerson defended the cuts, saying “Our budget will never determine our ability to be effective. Our people will.”
Good news came with the nomination of former Ambassador and Congressman Mark Green to lead USAID. Green was well received by both political parties in his testimony before the Senate Foreign Relations Committee on June 15, and he talked with pride about the work of USAID (we also learned that his parents were born South African and British).
For global health advocates, one of the most worrisome aspects of Trump Administration policy has been the reinstatement and expansion of the Mexico City Policy. This policy requires foreign non-governmental organizations to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source as a condition for receiving U.S. family planning assistance.
Green tried to calm concerns about the policy. “The State Department is undertaking an intensive six-month review to study the impacts of the expanded policy and whether it leads to interruption of services on the ground,” said Green in his testimony. “USAID will be part of that and we will play it straight. You can count on us to be honest brokers in that process.”
In the U.K., meanwhile, a different scenario has been playing out. In 2013, the UK became the fifth country to reach the UN goal of dedicating 0.7% of its gross national income to foreign aid, driven in large part by former Prime Minister David Cameron. But after the Brexit upset in 2016, Theresa May became prime minister and appointed conservative Member of Parliament Priti Patel as her international development secretary.
At the time, Patel roundly criticized British aid as being a waste of money and promised a major overhaul of the aid budget, according to the Daily Mail.
“My approach will be built on some core conservative principles — that the way to end poverty is wealth creation, not aid dependency; that wealth is ultimately created by people, not by the state; that poor countries need more investment and trade, not less,” she was quoted in The Guardian. “And we need to empower the poorest to work and trade their way out of poverty, not treat them as passive recipients of our support.”
In March 2017, a cross-party parliamentary committee on international development concluded that “ODA [official development assistance] spending is in the national interest and is a strong investment contributing to create a more prosperous world, which pays far-reaching dividends including to UK taxpayers at home.” The committee did not find evidence of wasteful spending. In fact, they found the spending to be effective.
Recently, Patel has struck a more positive tone about ODA. She announced a new aid package for east Africa, boasted about the scale of UK development assistance and, when asked about the future of UK aid, said: “It’s never been so needed. We face more global challenges in 2017 than every before.”
We don’t know if global health funding will go up or down but one thing is clear: Green and Patel are both interested in finding approaches to foreign aid that go beyond treating people as passive recipients of cash and that spark more economic investment and trade. It will be interesting to see what that means for global health.
Health Workers, Facilities Under Attack in 23 Nations; UN Accused of Inaction
23rd May 2017
By David J. Olson
In 2012, two Pakistani health workers were out vaccinating children against polio when they were both shot by extremists. One of them died. The other, shot in the leg, had 11 metal rods inserted into his leg and was hospitalized for three months.
In November, I met this remarkable man named Latif (his surname is withheld to protect his security). He is now fully recovered and back to work on the polio vaccination campaign. He told me he never considered giving up. Pakistan reported only two cases of wild poliovirus in 2017 as of May 17 and Latif is determined to see the polio campaign through to the end.
The attack on Latif is only one example of a tragic phenomenon that is not getting better – violence against heath workers and health facilities. In 2016, the extent and intensity of such violence “remained alarmingly high,” according to a new report released by the Safeguarding Health in Conflict Coalition.” The report also found that accountability for committing these attacks remains inadequate or non-existent.
The violence isn’t always perpetrated by terrorists. Sometimes it is committed by the police or the country’s military — institutions that should be ensuring tranquility.
Most of us have heard of hospitals and clinics getting blown up or polio vaccinators getting shot but the report indicates that attacks on health care take many forms. It names eight different forms of violence:
- • Bombing and shelling of health facilities (reported in 10 countries in 2016)
- • Looting of health facilities (11)
- • Killing of health workers, emergency medical personnel and patients (11)
- • Intimidation, assault and arrest of health workers and patients (20)
- • Abduction of health workers (11)
- • Obstruction of access to care including blockage of and attacks on ambulances (10)
- • Takeover and occupation of health facilities by police, military or other armed actors (7)
- • Attacks on and blockage of humanitarian actors, supplies and transports (15)
The report documents attacks on health care in 23 countries in 2016. Most of the countries are in Africa and the Middle East but there are a few exceptions (Armenia, India, Myanmar and Ukraine). The report was released on May 3, the first anniversary of the UN Security Council’s adoption of Resolution 2286 that set out a roadmap to the protection of health workers in conflict.
The Safeguarding Health in Conflict Coalition says the UN Security Council has failed to follow through on its own recommendations for preventing attacks and providing accountability for those who commit them. These recommendations include regular reporting to the UN on actions taken to prevent attacks, to investigate attacks, and to hold perpetrators accountable. The U.N. Press Office did not respond to my request for a comment.
“Our findings cry out for a level of commitment and follow-through by the international community and individual governments that has been absent since the passage of Security Council Resolution 2286 a year ago,” said Leonard S. Rubenstein, chair of the coalition and director of the Program on Human Rights, Health and Conflict at Johns Hopkins University Bloomberg School of Public Health in a press release issued on the anniversary.
The International Committee of the Red Cross, which has had a campaign called Health Care in Danger since 2011, says the attacks have increased despite the commitments. The slogan of the campaign is “Everyone wounded or sick has the right to health care.”
In Pakistan, doctors supervising the polio vaccine campaigns and police protecting community health workers were shot and often killed in a number of attacks. Many of these attacks took place in areas where wild polio virus is endemic. In August, a suicide attack at Quetta Civil Hospital in Quetta left 74 civilians dead and up to 112 wounded. Though it targeted a group of lawyers and journalists who were mourning a colleague, this bombing was one of the deadliest attacks on a medical facility in the history of the region, according to the report.
In Mali, Human Rights Watch reported that on at least six occasions, ambulances and other vehicles used to transport patients and deliver health care were attacked or robbed. In four of these incidents, sick passengers, drivers and health workers were forced out of the vehicles and robbed and the vehicles stolen. In another incident, an improvised explosive device struck an ambulance that was headed to the scene of another IED attack that killed two peacekeepers.
Syria was the worse country in terms of intensity and impact of the attacks. Physicians for Human Rights reported 108 attacks on health facilities in 2016, most by the country’s own military and Russian forces, and the death of at least 91 health workers.
These are just a few examples of the many tragic incidents in 23 countries detailed in the report.
It is clear that these attacks can have profound effects on the availability of health care. They result in:
Suspension of health programs
- • Degradation of the health infrastructure
- • Exodus of health workers concerned about their security
- • Outbreaks of disease and illness and inability to treat existing conditions
Accountability for such reports is largely absent, according to the report. A review by Human Rights Watch of 25 major incidents of attacks on health care between 2013 and 2016 found that either no investigations at all were pursued, or the investigations were inadequate.
As bad as the situation is, the numbers noted in the report may only be the tip of the iceberg because there are surely many attacks that go unreported. And the danger goes beyond the health workers who bear the initial brunt of the attacks.
“Although attacks on health workers are obviously dangerous for the workers themselves, they are also a danger to the communities they serve,” said Laura Hoemeke, director of communications and advocacy at IntraHealth International, one of the key members of the coalition. “If they do survive the attacks, many flee their communities and countries, leaving behind people with even less access to health care. This limited access has a particularly negative impact on maternal, newborn and child health.”
It is bad enough that anyone, anywhere has to do without health care. But to deny healthcare to those living in a state of war or unrest is unconscionable. As The Lancet commented, “One attack on a health worker is one too many.”
Tremendous Progress Against Malaria Seen But Challenges Remain
25th Apr 2017
By David J. Olson
When I was a young development worker, I engaged in high risk behavior one night in a village in Mali: I slept without a mosquito net. A week or so later I contracted malaria.
Of all the diseases I have written about here, malaria is the only one with which I have personal and intimate experience. And it was not pleasant. It was so debilitating, so sapping of my energy, I remember not caring whether I lived or died.
Fortunately, I was an otherwise healthy young male and bounced back briskly after a week or so of misery. In fact, I have lived long enough to see the beginning of the end (or at least the decline) of this global killer: In December, the World Health Organization (WHO) released the World Malaria Report 2016 in which it estimated that 1.3 billion fewer malaria cases and 6.8 million fewer malaria deaths occurred between 2001 and 2015 than would have occurred had incidence and mortality remained the same. About 97% of those deaths averted were for children under five years (who are most vulnerable to the disease, along with pregnant women).
Buried on Page 50 of the report is the gist of what makes this news so exciting: In WHO’s Africa Region, these reduced malaria mortality rates have translated to a rise in life expectancy at birth of 1.2 years, accounting for 12% of the total increase in life expectancy of 9.4 years, from 50.6 years in 2000 to 60 in 2015.
This means more children — many more children — will survive the perils of childhood in Africa and go on to lead productive lives as adults. This makes malaria control one of the most exciting developments of many encouraging global health trends in recent years.
Today we mark World Malaria Day with the message “Let’s close the gap” in malaria prevention. It’s a time to celebrate the tremendous accomplishments to date, but also to remember how many challenges remain. For example, an estimated 43% of people at risk in sub-Saharan Africa are still not protected from malaria, according to WHO. And there were still 212 million cases of malaria worldwide in 2015.
Dr. Richard Cibulskis, coordinator of Evidence and Economics of the WHO Global Malaria Programme, told Global Health TV that we have good reason to be optimistic about the fight against malaria.
“We’ve had huge success in bringing down malaria incidence and mortality rates over the last fifteen years. We have effective tools to prevent, diagnose and treat the disease, and coverage of these tools has been massively scaled up in many countries. There are exciting new technologies under development, and more countries than ever are making progress towards elimination.”
“But there are also some worrying trends, especially the fact that global funding seems to be flat-lining. We can eliminate malaria, but only if we can continue to harness the financial and political will needed to accelerate progress and make new and existing tools available to all who need them.”
Insecticide-treated bed nets are one of the biggest successes in malaria control. The World Malaria Report found that 53% of the population at risk in Sub-Saharan Africa slept under a net in 2015 compared to 30% in 2010. Furthermore, WHO found that people who slept under nets had significantly lower rates of malaria infection than those who did not use a net.
And it was announced yesterday that the world’s first vaccine against malaria will be tested in Ghana, Kenya and Malawi in 2018. The vaccine has the potential to save tens of thousands of lives but it is unclear if it is feasible to get parents to bring their babies in four separate times to get the required doses.
Malaria control has had solid bipartisan support in the U.S. for 15 years. The U.S. government – the largest donor to global malaria efforts – has increased its support from $146 million in 2001 to $861 million in 2016. Funding really took off after former U.S. President George W. Bush launched the President’s Malaria Initiative in 2005.
Last month, U.S. President Donald Trump released a proposed budget that calls for close to a one-third reduction in foreign assistance. We don’t know how those cuts – which still have to be approved by a dubious Congress – would affect malaria control but it does cause concern.
What we do know is that President Trump has announced plans to meet U.S. commitments to the Global Fund for AIDS, TB and Malaria, according to this analysis by Friends of the Global Fight.
The WHO’s Global Technical Strategy for Malaria calls for malaria to be eliminated in at least 35 countries by 2030. Dr. Cibulskis call this “an ambitious but achievable target.”
“But even if this target is achieved, it could still leave us with more than 50 countries in which malaria is endemic,” he says. “A challenge will be maintaining robust funding and political commitment as we continually make progress towards this goal.”
One of the problems the malaria control community worries about is that once cases and deaths have decreased and the disease seems like less of a threat, funding for malaria could be cut.
“History has shown us that we must keep our levels of investment high, or risk a resurgence of the disease and a reversal of progress made to date,” says Dr. Cibulskis. “We cannot let up in our efforts until we get the job done.”
Promoting Contraceptives To Adolescents in Mexico? Make the Campaigns Fun
21st Mar 2017
By David J. Olson
MEXICO CITY, Mexico — I met the three young women at a reproductive health clinic in Iztapalapa, the most populous and fastest-growing borough of Mexico City, with a population of 1.8 million on the eastern side of the capital city.
Ariatne and Isis, both 20 years old, each have one child. Monserrat was their aunt, but didn’t look much older. She had three children. All of them were looking for a way to space the birth of their next child. One of them wanted to wait five years; another, ten years.
All of them had chosen intrauterine devices (IUDs) as their contraceptive, one of them told me, “because they are comfortable and secure.”
Although unplanned pregnancy is a big problem in Mexico (and the rest of Latin America), good sexual and reproductive healthcare is hard to come by in Mexico, especially for adolescents, according to a recent study.
Almost three-quarters of pregnancies among adolescents aged 15-19 in the region are unplanned, according to the Guttmacher Institute, and about half of those end in abortion. Among all women 15-19 who need contraceptives, 36% of them are not using a modern method. The unmet need is highest in Central America, where 46% of sexually active adolescents who want to avoid pregnancy are not using modern contraceptives.
DKT México, a non-governmental organization that uses social marketing to prevent HIV and promote contraception in Latin America and the Caribbean, has learned some lessons about how to promote contraception to young people after success in promoting condom use but failing to do the same with contraceptives after they took a more traditional approach.
In 2015, DKT México launched a family planning campaign focused on increasing awareness of pregnancy among teenagers and young adults. They opted for a serious, medical campaign in traditional pharmaceutical company style — they talked in the negative and expounded on the myths of various contraceptive methods.
The campaign failed. Few young people attended their events or engaged their digital media. Their messages did not resonate with the audience they were trying to reach. This translated into poor contraceptive sales.
At the same time, they were having a highly successful Prudence condom campaign with well attended events a Facebook page with 2 million followers and a Twitter account with 47,500 followers. Their condom sales tripled between 2012 and 2016.
The contrast between the two campaigns strongly suggested that they had to apply the same fun strategy of openly talking about sex in their family planning work as they were doing in their condom work. So they made major changes to their campaign:
•They avoided talking in the negative and focusing on myths. Instead, they focused on the positive results of contraception.
•They realized that most Mexicans think of babies as a blessing from God, and it doesn’t help to talk of “unwanted” pregnancies, so they changed to “unplanned pregnancy.”
•They shifted the focus to how these unplanned pregnancies can interrupt education, travel and careers, things about which young people care very much.
•They stopped using the term “family planning” and started talking about “life planning.” Young people do not think in terms of family planning; they are more interested in planning their education, careers and other life goals. This is true not only in Mexico but in other countries as well, something I wrote about here.
“In short, we stopped being preachy and started being fun, adopting the same entertaining messages and approaches we were using to market Prudence condoms at schools, concerts and fairs,” said Karina de la Vega Millor, director general of DKT México. “The main message became ‘Have sex, have fun, but use double protection against a sexually-transmitted disease or an unplanned pregnancy that will change the course of your life.’”
“These tools give fun messages about the importance of having a life plan and avoiding pregnancy until you are ready, said Millor. “There are plenty of ribald jokes, frank discussions and flirty talk full of double entendres to engage our audiences. Our Facebook page now has more than 1.1 million followers, and more engagement than any Facebook page dedicated to contraception in all of Latin America.”
The clinic I visited in Iztapalapa, where a majority of the residents are poor to middle class, is affiliated with RED DKT (DKT Network) which DKT started in Mexico a year ago to improve sexual and reproductive health and encourage use of long-acting reversible contraceptives like IUDs.
The bottom line is that DKT México learned from the mistakes of its first campaign. This new campaign promotes life planning, not family planning. It has resulted in more young people viewing DKT websites and social media platforms, sharing information with their friends and coming to DKT events and clinics to get information and products to help plan their lives.
And more of them are actually using contraception to avoid unplanned pregnancy. Millor says that DKT México has increased almost eight-fold its number of couple years of protection (the amount of contraception to protect a couple for one year) between 2012 and 2016. She said they estimate they contributed about 4% of all the couple years of protection in Mexico in 2016, according to DKT calculations. That may not sound like a lot until you realize that Mexico is the tenth most populous country in the world, with a population of 129 million.
DKT México is now expanding into Central America, the Caribbean and northern South America and it will apply the lessons it has learned in Mexico to these new countries.
Though Preventable, Cervical Cancer Causes Half Million Cases Per Year
28th Feb 2017
By David J. Olson
Over 16 years ago, Sally Kwenda survived colon cancer and HIV, and then lost her husband and two children to AIDS-related illnesses.
“Just when I thought I was done with the hurt and the pain, I was diagnosed with stage II cervical cancer,” she recalls. “Many of those I have met on this journey have either passed away or are worse off than me. Many of them got their diagnoses when it was too late to change the tide. Yet cancer does not have to be a death sentence. My experience reveals that cancer is curable.”
Cervical cancer is the most common cancer among women in Sally’s home country of Kenya as well as in 38 low- and middle-income countries, mainly in sub-Saharan Africa, according to the American Cancer Society (ACS).
The reasons for the high rates of cervical cancer in Kenya, according to Deborah Olwal-Modi, executive director of the Kenya Cancer Association, include lack of knowledge and awareness, inadequate facilities for prevention and treatment, economic barriers, and co-morbidity of cervical cancer and HIV/AIDS. For example, almost all women (97 percent) do not know that a virus causes cervical cancer, according to a new study among women in major Kenyan cities.
Worldwide, there were an estimated 528,000 new cases and 266,000 deaths from cervical cancer in 2012, with more than 86% of those deaths occurring in less developed countries. Last year in India, it killed almost 70,000 women. And the situation is getting worse: The number of deaths is projected to rise to 443,000 annually by 2030, according to the World Health Organization (WHO).
And yet vaccination, early screening and treatment of precancerous lesions can prevent most cases of cervical cancer. In fact, ACS says cervical cancer is one of the most treatable cancers. In the U.S., for example, the cervical cancer death rate has declined by more than 50 percent over the last 30 years.
“HPV vaccination given to adolescent girls and inexpensive screening techniques replacing the too expensive, too complicated Pap smear could bring cervical cancer under control within a generation,” said Sally Cowal, senior vice president of global health at ACS.
Virtually all cases of cervical cancer are caused by the Human Papillomavirus (HPV) infection through sexual contact, and the optimal time for acquiring infection is shortly after becoming sexually active. That is why the WHO recommends vaccinations for girls aged 9-13 which WHO says is the most cost-effective measure against cervical cancer
Yet some parents seem to have a problem taking their young daughters in for a vaccination against HPV to protect them against infections which may seem far in the future and which is transmitted sexually. In the U.S., a 2014 study published by the U.S. Centers for Disease Control and Prevention showed that only 39.7 percent of girls aged 13-17 had received the full three doses of the HPV vaccine, much lower than the 87.6 percent of boys and girls of the same age that received tenanus-diptheria-acellular pertussis vaccinations.
In a report launched in conjunction with World Cancer Day on Feb. 4, the WHO said that the early diagnosis of cancer and prompt treatment, especially for breast, cervical and colorectal cancers, would lead to more people surviving the disease and cutting treatment costs. “Not only is the cost of treatment much less in cancer’s early stages, but people can continue to work and support their families if they can access effective treatment in time,” said the report.
How much would it cost to implement HPV vaccination in developing countries? Based on a study supported by ACS, Harvard T.H. Chan School of Public Health experts have estimated that approximately 60 million girls in 17 high-burden, low-income countries could be immunized over five years at a cost of approximately $800 million or $13.40 per fully immunized girl. If the U.S. government committed to funding 20% of that, it would equate to about $160 million, or $32 million per year.
But current funding is not well aligned with the actual burden of disease in countries where the U.S. governments supports health programs. “While more than a quarter of deaths in priority low- and middle-income countries is from chronic diseases, such as cancer,” says the ACS, “virtually no funding is provided to prevent those deaths.”
World Cancer Day was Feb. 4 and the theme was “We can. I can” and explores how everyone can do their part to reduce the global burden of cancer.
Certainly Sally Kwenda is playing her part. She is now a Relay for Life “Hero of Hope” (Relay for Life is an annual athletic event to raise funds and awareness for cancer education) with the Kenya Cancer Association and spends her time connecting with other cancer survivors and using the knowledge she has acquired to empower and encourage them.
“The best warrior is not the one who always wins the battle but the one who is not afraid to go back to the battlefield. My plea to every single person is: Now is the time to act. It is time to beat this disease. I strongly believe this is possible.”
The Lancet has just published a special issue on breast and cervical cancer on Feb. 25, 2017.
Global Health Film on Refugee Struggle Continues to Gain Global Recognition
24th Feb 2017
London, UK – Back in May 2016, Global Health TV travelled to the heart of ‘Tent City’ one of Lebanon’s most over populated refugee regions – The Bekaa Valley. Working with World Vision, Global Health TV witnessed first-hand how the Lebanese Cash Consortium, a humanitarian aid coalition, provided financial assistance to Syrian refugees – empowering them to buy items fundamental to their survival, such as clean water, food, medicine and shelter.
Living Below the Line: Life as a Refugee in Lebanon is a Global Health TV film that shares the story of Hajar, a mother of four, who fled her home town of Al Kusayr (Syria) with her children, after her husband went missing during heavy shelling. ‘We were living in our own house, now we are living in a tent… our life here has its effects on the children, it reflects on their faces. It effects their health too’ she said. Hajar is one of the many recipients of the financial assistance provided by the Lebanese Cash Consortium, of which World Vision is a member of.
“There is no doubt that cash modality in the humanitarian response is one of the most efficient, effective, fast, innovative, creative and dignifying way to assist vulnerable population. The consortium along with ECHO (European Commission of Humanitarian Aid and Civil Protection) and DfID (Department for International Development) are trusting people with money and trusting that they know better what they need most,” said Patricia Mouamar, Communications Manager at World Vision International.
Since its debut at the first ever World Humanitarian Summit, organised by World Health Organization (May 2016), the film continues to gain recognition – awarded gold at the 2016 MarCom Awards and more recently receiving an honourable mention at the 2017 AVA Digital Awards.
Through raising the profile of this humanitarian issue, Living Below the Line: Life as a Refugee in Lebanon, highlights the importance of co-ordinated efforts, particularly between aid agencies to help those who need it the most. Now more than ever, this joint collaboration is needed to address the growing number of refugees, asylum-seekers and displaced people around the world which has now exceeded 65 million, according to The UN Refugee agency.
Watch the full story of Hajar and the situation in Lebanon below
Lebanese Cash Consortium provides assistance that empowers refugees to make their own decisions with dignity. www.lebanoncashconsortium.org
World Vision International is a global Christian relief, development and advocacy organisation dedicated to working with children, families and communities to overcome poverty and injustice. Visit www.wvi.org for more information.
As Infectious Disease Falls, Chronic Disease Increases; Possible Solutions Emerge
31st Jan 2017
By David J. Olson
As 2017 begins, we celebrate the fact that many diseases of developing countries have been significantly reduced in recent years. The numbers of people suffering from HIV, malaria and tuberculosis are in decline.
But as communicable diseases wane, non-communicable diseases (NCDs) wax (like cancer, diabetes, cardiovascular and chronic respiratory diseases).
This was hammered home by the Institute for Health Metrics and Evaluation (IHME) of the University of Washington which, just in the last two months, released three new reports that provide further evidence of this trend:
• Almost 20% of global deaths in 2015 were linked to elevated blood pressure, according to the latest Global Burden of Disease study. The number of people in the world with high blood pressure, including hypertension, has doubled in the past two decades, putting billions at increased risk for heart disease, stroke and kidney disease.
• Cancer is growing almost everywhere in the world but the greatest increase between 2005 and 2015 occurred in the poorest countries that are least equipped to deal with it, according to a new analysis.
• 30% of all deaths from diabetes worldwide occur in the poorest countries bringing a double burden of disease – from communicable and non-communicable disease – to many countries in Africa, according to a new IHME report. Women often bear most of the burden.
Of course, NCDs are not a new problem. However, they are increasing both in scale and visibility because of the transition from low-income to middle-income status, the influence of globalization on diet and consumption patterns and greater longevity as people increasingly survive childhood illness and communicable disease, according to an analysis by the Kaiser Family Foundation.
Despite the rising tide of NCDs, though, little money has been invested to prevent and treat them. In Financing Global Health 2014, IHME said that development assistance for health (DAH) directed towards NCDs is one of the smallest health focus areas they estimate and was only $611 million in 2014, just under 2% of total DAH. The first graph on page two of this brief shows just how little NCDs are funded compared to communicable disease and child health.
“The productivity loss for NCDs is estimated to be $500 billion annually yet almost no donor funding is being deployed against them,” said Dr. Harald Nusser, global head of Novartis Access and Novartis Malaria Initiative. “We need robust funding for both communicable and non-communicable disease, and more robust health systems in general to start turning our efforts towards NCDs while not relenting in the fight against AIDS, malaria and tuberculosis.”
“NCDs share all the ideological and social justice issues of HIV but cause 30 times more deaths and receive 17 times less funding,” writes Luke N. Allen and Andreas B. Feigl in a new commentary in The Lancet Global Health.
Even communicable disease experts see how the disease burden is shifting to NCDs. Charles Nelson, chief executive of the Malaria Consortium, talks about how malaria death have fallen between 2000 and 2015 while NCDs are rising. Nelson said disability-adjusted life years (DALYs), which is a measure of overall disease burden, coming from communicable maternal, perinatal and nutritional diseases is decreasing while DALYs from NCDs is increasing, said Nelson. This is true globally, as well as in Africa and Southeast Asia.
Kenya seems to be the focus of much of the research as well as some of the earliest attempts to deal with NCDs in Africa.
A report on the burden of disease in Kenya found that the country has made tremendous progress in dealing with communicable disease and maternal and child health but that the burden of NCDs was growing, with the health loss from NCDs growing from 19% in 2000 to almost 30% in 2013.
Three new efforts, all led by pharmaceutical companies, are trying to address NCDs in Kenya:
• In 2015, Nusser helped launch Novartis Access which makes 15 on- and off-patent medicines available to treat NCDs at $1.00 per treatment per month.
• AstraZeneca’s Healthy Heart Africa program conducted one million hypertension screenings in Kenya, opened over 250 health facilities, trained over 2,600 health care workers, diagnosed close to 150,000 patients with high blood pressure and started treatment for 25,000 patients in its first year.
• Novo Nordisk is expanding its Base of the Pyramid Project, a sustainable initiative rolled out in 2010 to facilitate access to diabetes care for the working poor in low- and middle-income countries. The project has screened more than 20,000 people for diabetes.
And a major initiative involving 22 biopharmaceutical companies just launched Access Accelerated, a global initiative to increase access to NCD prevention and care in low- and lower-middle income countries, at the World Economic Forum on Jan. 18. Access Accelerated is supported by $50 million in funding and a pledge of increased individual company programs focused on NCDs.
The NCD movement has long been hobbled by its unwieldy name – non-communicable diseases. “A name that is a longwinded non-definition, and that only tells us what this group of disease is not, is not befitting of a group of diseases that now constitute the world’s largest killer,” writes The Lancet Global Health, which calls for a change in terminology (and offers a few suggestions) to bring needed and deserved attention to these diseases.
The End of Trachoma, World’s Leading Cause Of Preventable Blindness, Is in Sight
13th Dec 2016
By David J. Olson
In 1988, as a young development worker for Lutheran World Relief in Mali, I was showing a group of American Lutherans our development projects in Dogon Country, when we came across a tragic situation — a young boy with a severely inflected eye, where he had lost his sight, with menacing flies hovering around the other, still good eye.
It was a heart-wrenching scene for these people, most of whom were on their first trip to Africa. One woman took pity on the boy and, after returning to the U.S., raised money for his treatment. I took the boy to the best hospital in the country in the capital Bamako. Doctors removed his infected eye, and replaced it with a glass eye. Without treatment, he surely would have gone completely blind.
That was my first exposure to trachoma, the world’s leading infectious cause of blindness in the world. Trachoma — a bacterial eye infection found in poor, isolated communities lacking basic hygiene, clean water and sanitation – continues to plague Mali and 40 or so other countries.
What is trachoma? It is a disease of the eye caused by infection with the bacterium Chlamydia trachomatis that is spread through personal contact and by flies that have been in contact with discharge from the eyes or nose of an infected person. If the infection persists, the inside of the eyelid becomes so scarred that it turns inward and causes the eyelashes to rub on the eyeball, causing pain, discomfort and permanent damage to the cornea.
The World Health Organization estimates that trachoma is responsible for the blindness or visual impairment of 1.9 million people in 42 countries, with just over 200 million people at risk of trachoma blindness.
The Carter Center, best known for its work on Guinea worm (which is close to elimination), is now focusing on its next miracle – the elimination of blinding trachoma by 2020. The Center works to control and prevent trachoma in six of the 31 countries actively implementing a prevention strategy (Ethiopia, Mali, Niger, Sudan, South Sudan and Uganda).
Just last month, WHO declared Morocco to be the eighth country to eliminate trachoma as a public health problem. The other countries are China, Gambia, Ghana, Iran, Mexico, Myanmar and Oman.
The Carter Center says that in order to eliminate blinding trachoma, all four components of the SAFE strategy must be implemented: Surgery for advanced disease, Antibiotics to clear infection, Facial cleanliness and Environmental improvement to reduce transmission (particularly, improving access to water and sanitation).
In September in Washington, D.C., the Carter Center screened a documentary film from award-winning producer Gary Strieker and Cielo Productions called “Trachoma: Defeating a Blinding Curse,” in which a film crew followed Carter Center staff and other health professionals around Ethiopia for seven years in the Amhara Region, Ethiopia, the most endemic region of the most endemic country.
Strieker, a former CNN correspondent based in Africa, talked about the power of the story of the fight against trachoma.
“Most of the stories I covered in Ethiopia over the years were not very encouraging – famines, droughts, revolutions,” he recalled. “Ethiopia was always in the portfolio – one of those hopeless cases where you could be sure that whatever was coming out of Ethiopia would be bad. People had no hope. You could see it wherever you went.”
“But as we watched the trachoma campaign develop, the sustained effort by the government and the people to carry this out, we saw thousands of health workers mobilized, so much enthusiasm and making it happen in front of our eyes, year after year. They set an example for the rest of Africa and the developing world. It’s a great testament to what can be done if the government has the political will and actually reaches the people and gets them to work in their own interests. It’s been so encouraging and such a wonderful story.”
Kelly Callahan, the Carter Center director of the Trachoma Control Program, said that the trachoma campaign success happened because it was done with a “bottom-up structure.”
“The government is not telling people what to do, when to do it and how to do it,” she said. “It’s the people that are driving the force. If the people are driving it, they own it, they feel empowered and they feel they’re doing something together. If the community doesn’t own the program, then it’s not sustainable and it will not improve their lives.”
Trachoma foes believe the goal of elimination by 2020 is realistic even though much works remains to be done. A massive mapping exercise was conducted in 2013 to help understand better the scale of the problem outside of the Carter Center-assisted countries. Since then, activities have increased in most of these places. The Carter Center-assisted countries should achieve 2020 goal, Callahan said, through a strong commitment of the government in each country, the communities, the partners and the global alliance.
Trachoma control is not only the moral thing to do, it makes good economic sense. Trachoma prevention and treatment is one of the best buys in global health, according to Paul Emerson of the International Trachoma Initiative. Every dollar invested in trachoma reaps thousands of dollars in savings, Callahan said.
Callahan thinks the elimination of trachoma will have an impact beyond trachoma. “If someone’s suffering from trachoma, they’re probably suffering from river blindness, probably co-endemic for schistosomiasis, soil-transmitted helminths and lymphatic filariasis. If you pile on these diseases, their immune systems are so suppressed that HIV, TB and malaria – the big killers – can come in. So if we can get rid of Guinea worm and trachoma and pluck every single one of these diseases, imagine immune systems that are not suppressed from neglected tropical diseases. Just think of the quality of life. That’s immeasurable.”
Golden Recognition for Living Below the Line: Life as a Refugee in Lebanon
6th Dec 2016
Global Health TV has been recognised with gold at the 2016 MarCom Awards for the film Living Below the Line: Life as a Refugee in Lebanon. It debuted in May at the first ever World Humanitarian Summit, organised by World Health Organization. Living Below the Line was one of 6,500 entries submitted to the MarCom Awards from across the globe and highlights the situation in Lebanon and the importance of joint collaboration between agencies to help those in need.
Executive Producer Cath Sheehan worked with World Vision and with a local crew to capture the reality for Syrians who escaped from conflict, and are now living in a Lebanese refugee camp. World Vision is one of six aid agencies working together in the region as a part of the Lebanese Cash Consortium (LCC). Providing refugees with financial assistance, the LCC enables them to identify and prioritize the issues most pressing to them and their family.
“There is no doubt that cash modality in the humanitarian response is one of the most efficient, effective, fast, innovative, creative and dignifying way to assist vulnerable population. The consortium along with ECHO (European Commission of Humanitarian Aid and Civil Protection) and DfID (Department for International Development) are trusting people with money and trusting that they know better what they need most,” said Patricia Mouamar, Communications Manager at World Vision International.
“Recipient of the cash assistance are optimizing the use of money, like Aida a Syrian mother I met in Lebanon, who managed to use the cash to pay the cab 20,000 LBP (13USD) and ran to the emergency room, when her seven year old child was in an urgent need of hospitalization when boiled water caused him severe skin burns,” said Patricia Mouamar.
Global Health TV is a platform to communicate the work of the global health community, sharing stories that advance knowledge and response to global health issues. www.globalhealthtv.com
Lebanese Cash Consortium provides assistance that empowers refugees to make their own decisions with dignity. www.lebanoncashconsortium.org
World Vision International is a global Christian relief, development and advocacy organisation dedicated to working with children, families and communities to overcome poverty and injustice. Visit www.wvi.org for more information.
Please contact: Sally Nelson, Global Health TV, email@example.com
Polio’s Days Are Numbered As Teams Close in on Last Few Cases in 3 Countries
23rd Nov 2016
By David J. Olson
By David J. Olson
PARIS, France — In 2012, Latif and his colleague were vaccinating children against polio in Pakistan when they were shot by extremists. Latif was shot in the leg. He had 11 metal rods inserted into his leg and was hospitalized for three months. His colleague died. Today, fully recovered and undeterred, Latif (his surname is withheld to protect his security) continues his anti-polio crusade in northwestern Pakistan.
Jim Costello, 73, contracted polio at the age of 15. It paralyzed his upper body: He has triple curvature of the spine, wears a spinal brace and has no use of his arms. His lungs are 75% paralyzed and he uses a medical ventilator for about 18 hours daily. He lives at home in Dublin, Ireland with his wife Delia, “my beloved partner of over 30 years,” on the weekends. During the week, he is in the hospital where he still uses an iron lung. Despite these limitations, he has led a productive life in the retail clothing business and in support of polio survivors. Since 1993, he has served as chairperson and board member of Post-Polio Support Group Ireland
Latif and Costello were two of five people honored as “polio heroes” at a World Polio Day event Oct. 24 at the Pasteur Institute here sponsored by Sanofi Pasteur and Rotary International, two organizations deeply invested in the fight against the disease. Meet Latif in this video and Khuram (an employee of Sanofi Pasteur) in this video (videos from Sanofi Pasteur/AKS Films).
Participants heard experts say that the world is tantalizingly close to eliminating polio, and that elimination could happen in 2017. As of last week, there were only 32 remaining cases of wild poliovirus — 16 in Pakistan, 12 in Afghanistan and 4 in Nigeria. We are on the brink of eliminating the second human disease in history (smallpox, in 1980, was the first).
It is true that all three countries have security challenges. But in Pakistan, the country with the largest number of remaining cases, the security situation has improved markedly since 2014.
“There were close to half a million kids not reachable due to insecurity in 2014,” said Dr. Mufti Zubair Wadood, technical officer for the Global Polio Eradication Initiative at the World Health Organization (WHO) and former head of the WHO polio program in Pakistan. “Since then, the situation has been improving and right now there are almost no areas of the country that are not accessible. That has resulted in a significant drop in the number of cases. Pakistan deserves a huge pat on the back at a time when things were dire.”three countries have security challenges. But in Pakistan, the country with the largest number of remaining cases, the security situation has improved markedly since 2014.
Wadood believes the next six months presents an excellent opportunity because this cooler period is when the vaccine works best and the virus is not transmitting at a high rate. “If good campaigns are implemented in the next 3-6 months, there is no reason we cannot stop it in late 2016 or early 2017,” said Wadood.
The polio eradication campaign is the largest public health program in history. For nearly 30 years, national governments, WHO, Rotary International, the U.S. Centers for Disease Control and Prevention and UNICEF have worked on this issue. More recently, the Bill and Melinda Gates Foundation joined the effort.
Sanofi Pasteur is, by far, the biggest supplier of polio vaccine in the world. It has provided 6 billion doses of the oral polio vaccine over the last decade and more than 1 billion doses of the inactivated polio vaccine, through injection, which will protect people once polio is eradicated.
But polio vaccination will continue for years after eradication, said David Loew, executive vice president of Sanofi Pasteur. Loew said that Sanofi is even considering building a second factory in order to develop the production capacity necessary to produce the injectable version.
Polio eradication is not only a global health success but also an economic success. Eradication is expected to save between $40 and $50 billion during the period 1988 to 2035, according to Dr. Kimberly Thompson, professor of Preventive Medicine and Global Health at the University of Central Florida. “Polio eradication represents a gift from our generation to future generations.”
Elimination may be near but Latif, the Pakistani polio hero, is not ready to declare victory quite yet. “I want the children of my country to be healthy and protected from polio. I have participated in this fight from the beginning and I want to continue to the end, to see a polio-free Pakistan.”
Did he consider giving up after extremists shot him in 2012? “No, I never thought of that,” he said. “As a matter of fact, I don’t connect the pain I felt with the work I do. They are two different things in my mind.”
Costello, the indefatigable polio survivor wanted to make two points:
If the people who attack vaccination teams could see me and people like me, is that really how they would like their own children to live their lives?
“I would like to appeal to the WHO, Rotary International and other organizations working to eradicate polio. When their job is done, which I know will be soon, would they please consider turning their valuable efforts towards the millions of polio survivors, particularly in underdeveloped countries, that now face the problems associated with post-polio syndrome?”
New Test to Detect HIV In Babies Boosts Hope Of Meeting UN Targets
25th Oct 2016
By David J. Olson
When Saquina, a 38-year-old single mother living in Nacala Porto, Mozambique, learned she was HIV positive while pregnant, she thought her life was over. Instead, she decided to accept her HIV status and follow the advice of the nurse who counseled her.
She did not miss any visits to the health center. She took the pills that helped prevent transmission of the virus to her unborn child. She participated in support groups with other HIV-positive mothers. When her son Frenchou was born, she gave him medication every day and breastfed him exclusively for six months.
When he was two years old, Frenchou was tested for HIV and found negative — another of many recent successes in the prevention of mother-to-child transmission (PMTCT), according to the Elizabeth Glaser Pediatric AIDS Foundation.
Between 2009 and 2015, there was a 60% decline in new HIV infections in children in the 21 priority countries, according to a UNAIDS report released in June. Seven of those countries reduced infections by more than 70%. A total of 1.2 million new infections among children were averted in these countries.
But if you thought thought that all is now well with PMTCT, and that we can move on to other HIV challenges, you would be mistaken. While a 60% drop is certainly encouraging, it is significantly below the 90% target set by the World Health Organization (WHO). UNAIDS has set a goal of eliminating all new HIV infections among children by 2020 while ensuring that 1.6 million children have access to HIV treatment by 2018.
Every day, an estimated 400 children are infected with HIV. When children with HIV are not diagnosed and treated promptly, as many as one-third will die before their first birthday and half before their second birthday.
But to achieve this goal, early infant diagnosis has been a major stumbling block. Up to now, infant testing has imposed a lag time between the test and the results of 3 to 6 weeks.
We know that if mothers and babies have to return to the clinic for test results weeks later, they are less likely to get the results and start treatment. “About 50 percent of infants who are tested do not receive their test results and, of those children who test positive, 40 percent never receive treatment,” notes the Elizabeth Glaser Pediatric AIDS Foundation.
That’s why a new technology for testing infants in less than one hour is so exciting. Alere, a U.S.-based company in rapid diagnostic products and services, says the test — called the Alere q HIV-1/2 Detect — is the first ever molecular diagnostic that identifies HIV-1 and HIV-2 in a health facility (Alere calls this “point-of-care testing”) in less than one hour. The technology allows HIV-positive babies to be put on treatment immediately. It also eliminates the problem of mothers not returning to the clinic for their test results.
Alere believes point-of-care testing will accelerate testing of infants, especially in South Africa, which has the highest HIV burden in the world. Currently, an estimated 11.2% of the population is living with the disease. South Africa is piloting the test in two health centers in the Western Cape.
“Currently, most newborns in developing countries are screened for HIV infection via dry blood spot testing, but because health workers have to wait 3 to 6 weeks for results many potentially HIV-positive infants are lost to follow-up and remain untreated,” said Dr. Landon Meyer, a professor at the School of Public Health and Family Medicine at the University of Cape Town. “The ability to provide to a patient’s mother a definitive test result — when before we would often conduct a test and mothers wouldn’t come back — the ability to provide that on-site within 52 minutes really is an epiphany. It’s a revelation.”
“There have been massive successes in PMTCT over the last decade, particularly in South Africa, but what we realize more and more is that the battle is not won and it’s going to be a very long time before we eradicate pediatric HIV infection, and so technologies like the [Alere] q become more important to us in practice.”
Pilots are also taking place in Malawi and Mozambique, and Kenya is looking at the possibility of using this test.
In June, Alere won prequalification from WHO, meaning the technology can be widely implemented by organizations and governments, and used by health workers to diagnose HIV infections rapidly, allowing for a more timely initiation of anti-retroviral therapy.
Anti-retroviral treatment is very effective in children with HIV, transforming it from a death sentence to a long-term, manageable condition, according to NAM. Many experts believe that treated children will have almost normal life expectancy.
If we can improve diagnostics and treatment, and deliver them to those children who need them, we will have more happy endings, like the inspiring 21-year-old Lerato, from South Africa, who was born with HIV. Now she says “There’s more to life than HIV. It’s not stopping me. I can do anything I want.”
A Long, Hard Road to Reversing Stagnation of Family Planning in Nigeria
27th Sep 2016
By David J. Olson
LAGOS, Nigeria — Lydia, a community health worker for DKT Nigeria, steps carefully as she navigates the grimy streets of Makoko, one of the worst slums of Lagos. She is trying to avoid mud or something worse. The sanitation is abysmal. But Lydia is on a mission — to bring contraception to some of the most disadvantaged women in Nigeria.
This day, she calls on Iya Lekan. Although neither Iya, 36 years old, or her husband have regular work or specific sources of income, they have five children to look after.
“I don’t know how many times I have given birth,” she says in Yoruba, the local language here. “I’m tired.”
Iya told Lydia she was ready to start practicing family planning. Lydia presented various options, and Iya chose a three-month injectable called Sayana Press. Lydia immediately gave her the injection in her upper thigh.
Some people think Sayana Press could be a game-changer. It’s a new version of the well-known Depo-Provera injectable contraceptive, but contains 30% less of the active ingredient and can be administered by lesser-skilled health workers. The United Kingdom has already approved it for self-injection.
Last month, I spent an afternoon with Lydia, a member of the DKT Bees, a group of community health workers (CHWs) who focus on family planning in some of the grittiest parts of Lagos. DKT calls their CHWs “bees” because they are like the hard-working insects that go from flower to flower spreading pollen. But instead of pollen, DKT Bees go house to house counseling, educating and dispensing contraceptives.
The road to greater contraceptive use in Nigeria has not been smooth. It’s shocking that the percentage of married women using modern contraception in Nigeria is only 9.8 percent (Nigeria Demographic & Health Survey 2013). That figure is lower than all countries in West Africa except Gambia, Guinea and Mauritania, according to the 2016 World Population Data Sheet, and has has hardly changed in the last ten years. Nigeria has a population of 187 million, making it the seventh largest country on earth. If current trends continue, it will be tied for third, with the United States, in 2050.
Clearly, family planning has stagnated in Nigeria since 1999. The reasons are many but certainly family planning myths and misinformation play a huge role. A DKT outreach worker told me that some of the most common questions she gets from Nigerian women are:
- What are the side effects of each method?
- Does family planning result in infertility?
- Does family planning increase body weight or make me fat?
- What do I do if bleeding occurs?
- Does contraceptive use predispose me to cancer?
The bottom line is that contraceptives are good for the health of women. In fact, Nigerian health experts blame the low uptake of family planning as one of the reasons why Nigeria still reports high maternal mortality.
The good news is that 16.1% of married women in Nigeria who are not using family planning want to start using it. The figure is even higher among sexually active unmarried women: 21.8 percent of them want to use contraception.
World Contraception Day on Sept. 26 provides a good opportunity to reflect on the current situation and what we can do to improve it in places like Makoko, so that every Nigerian woman who wants contraception can access it.
Decades of research have shown that modest investments in family planning can save lives and improve maternal and child health. And consider that family planning has been proven to be one of the most cost-effective health interventions. In short, family planning improves the economic well-being of families, communities and nations.
DKT Bees are one of the programs of DKT Nigeria, an affiliate of DKT International. DKT came to Nigeria in 2013 to help change the family planning paradigm. Using social marketing, it launched Kiss and Fiesta condoms, Postpill emergency contraception, Levofem oral contraceptive, Sayana Press injectable, Implanon NXT and Jadelle implants, Lydia intrauterine devices (IUDs) and Miso-Fem (Misoprostol). After only three years, it contributed 14% of Nigeria’s contraceptive prevalence rate in 2015.
Dimos Sakellaridis, the country director of DKT Nigeria, says he wants to make affordable contraceptives as easily available in Nigeria as Coca-Cola.
“Like women’s beauty products or hairstyles, modern family planning should be consumer-oriented and easy to understand, access and use,” he says. “When a woman wants to feel beautiful, she walks to a nearby store and buys a beauty product or service. Family planning should be obtained for the same consumer benefits — to enable women to feel beautiful by allowing them to manage their fertility and life.”
DKT Nigeria launched a new family planning communications campaign that coincides with World Contraception Day on Sept. 26. The target audience of its campaign is young women ages 18-34 (primary) and young men ages 20-34 (secondary) in the lower middle and working classes of southwest Nigeria. A new website, Honey and Banana, will serve as the central hub of the campaign and will be the destination for other traffic sources, such as Facebook, Twitter and Instagram.
The theme of the campaign is “Be Sharp.” The phrase is common slang that resonates with the target audiences. It means be smart, not dull. It means making the right decisions, especially concerning birth control and contraception, to avoid unwanted surprises.
Almost one in five people living in sub-Saharan Africa is a Nigerian. If enough girls and women are motivated to adopt contraception, the government will meet its goal of reaching 36% contraceptive prevalence rate by 2018, and their health will improve. It all comes down to community health workers like Lydia and the DKT Bees, going from house to house, taking one step at a time, to meet the needs of disadvantaged Nigerian girls and women.
The Next Great Pandemic: What Will It Look Like and Where Will It Come From
23rd Aug 2016
By David J. Olson
A few years ago, in a survey by epidemiologist Larry Brilliant, 90 percent of epidemiologists said that a pandemic that will sicken 1 billion, kill up to 165 million and trigger a global recession that could cost up to $3 billion would come in the next two generations. Currently, we’re living through three pandemics — HIV, Zika and cholera. What will the next pandemic look like and where will it come from?
Those are some of the questions science journalist Sonia Shah attempted to answer in an event marking the centennial of the Johns Hopkins University’s Bloomberg School of Public Health and in her book “Pandemic: Tracking Contagions from Cholera to Ebola and Beyond,” published earlier this year. The book should be required reading for anyone interested in the future of global health.
Shah spent six years trying to figure out how microbes turn into pandemic-causing pathogens. She looked at the history of pandemics, particularly cholera because it’s one of our most efficient pandemic-causing pathogens. She went to places where new pathogens are emerging to try to figure out what are the political and social drivers that push these microbes into human populations.
She found that one of the major drivers is wildlife. A disproportionate number of human pathogens come from other primates, who’ve given us 20 percent of our most burdensome pathogens (including HIV and malaria).
“About 60% of the new pathogens are emerging in animals,” she said. “Over 70% of those come out of wild animals. From bats, we’ve gotten Ebola, Nipah, SARS and Marburg, from birds we’ve gotten Avian influenza and West Nile virus, from rodents we’ve gotten Monkey Pox and Lyme Disease, from monkeys we’ve gotten malaria and HIV and probably Zika.”
The expansion of the human population is destroying wildlife habitat and this results in the remaining wildlife crowding in ever closer to humans.
“We’re creating more and more interfaces between humans and wildlife that allows for novel, more intimate kinds of contact in which the microbes that live in their bodies, can spill over into our bodies,” she said.
And animals, as well as humans, are crowding together. Shah says we have more animals under domestication today than in the last 10,000 years of domestication until 1960 combined. And an increasing proportion of these animals are living on factory farms, which she calls “the animal equivalent of slums, where you have hundreds of thousands of animals crowded really closely together where they’re breathing on each other, touching each other and being exposed to each other’s wastes. This is another opportunity new pathogens are exploiting.”
This new sanitary crisis is in addition to our old sanitary crisis in which 2.6 billion people don’t have access to any modern sanitation. In this new crisis, livestock produces 7 billion tons of excreta every year, which is far more than our crop lands can absorb. So we have giant open cesspools of untreated animal waste, which seeps into the environment.
And we’re spreading these pathogens around more efficiently than ever with extensive flight networks. Consequently, Shah says, even when one of these pathogens emerges in a place where there’s not a lot of susceptible people, it can quickly travel to a place where there are, to such an extent that we can predict where a pathogen will strike next by measuring the flights between infected and uninfected cities.
Since a lot of these pathogens are coming out of animals and driven through human populations by social and political factors, you would think that the best way to tackle this problem would be through an interdisciplinary approach. “Get the veterinarians, wildlife biologists, ecologists, engineers, anthropologists, political scientists, economists and bio-medical specialists together to look at the entire process,” she said. “But of course, that’s not what we do. We approach infectious outbreaks as solely a bio-medical phenomenon, reducing it to its smallest components, and then striking it down with surgical precision.”
Shah pointed out that Brilliant didn’t have a crystal ball. He was merely a warning of what will happen if we don’t change. She believes there is a lot that we can do with early detection, as this article points out. We don’t have to wait for the vaccines and drugs.
Ultimately, she said, we have to reduce the conditions that allow pandemics to occur, things like restoring wild habitats, so the microbes in animals stay in animals and do not cross over into humans. We have to protect the health of the most vulnerable among us, people who live in slums and animals in factory farms.
“We need to reimagine our relationship to the microbial world,” she said. “There is no ‘us’ and ‘them’ anymore. This is their planet, and they were here first. And they’re a lot better at living here than we are. We have to recognize that our health is connected to the health of our societies but also the health of our animals, our wildlife and our ecosystems.”
So what will the next pandemic look like? Shah says we don’t have a great track record predicting pandemics (no one predicted Zika) but sees two scenarios as the most likely:
1) A novel form of influenza, because influenzas are so efficient at spreading that even a slight increase in mortality from a virus would result in a huge number of deaths; or
2) An antibiotic-resistant bacteria, which poses a huge threat to public health because even a common injury like a scratch can become life threatening.
Shah says there is one thing that lets her sleep. “Look at it from the pathogen’s point of view. They need to transmit from one person to another but if they kill you too fast, they’re not going to be able to transmit very well. That helps me sleep.”
Controversy Brewing Over The Greatest Barriers to Access to Medicines
16th Aug 2016
By David J. Olson
In comments last week at the International AIDS Conference in Durban, South Africa, UN Secretary-General Ban Ki-moon said four things deserved credit for getting the AIDS pandemic under control — people living with HIV, biomedical companies, generic medicines and international finance.
But despite his gratitude to biomedical companies and generic medicines, the Secretary-General is overseeing a process that may threaten to undermine those companies’ ability to improve access to medicine in developing countries.
The World Health Organization says an estimated 2 billion people (27% of the world’s population of 7.5 billion) lack access to essential medicine, most of them in Africa and Asia, and a full three-quarters of the world’s population (around 5.5 billion) have no access to proper pain relief treatment.
To address this staggering problem, the Secretary-General set up a High-Level Panel on Access to Medicines earlier this year. The purpose of the panel was “to review and assess proposals and recommended solutions for remedying the policy incoherence between the justifiable rights of inventors, international human rights law, trade rules and public health in the context of health technologies.”
Sounds like a great and noble idea, right? But some expert commentators think the panel is on track to do more harm than good because of its terms of reference.
Secretary-General Ban Ki-moon told the panel to focus on intellectual property and the pharmaceutical companies’ protection of patents and ignore the other issues that hamper access to medicine — weak health systems, questionable government policies and a lack of doctors, nurses and community health workers.
Reports like this one suggest that the panel not only attacks the patent system but proposes to put the United Nations in charge of drug development. The High-Level Panel has said that the leaks may not be accurate and that the panel is still actively working on the report. The High-Level Panel was contacted for comment but did not respond before this article was published. When it is released, the report will be published on the panel’s official website.
There are so many more issues that influence access to medicines than intellectual property and patents. Some would argue that patents are not an obstacle to health at all but a tool to promote health.
“Far from being a threat to public health, patents are indispensable to promoting life-saving medical research,” writes Joseph Allen, who consults on intellectual property and formerly headed the National Technology Transfer Center.” If companies couldn’t protect their inventions through intellectual property laws, they’d have little reason to take the enormous risks involved in drug discovery. It’s not a coincidence that drugs are only created in a few countries with strong patent systems.”
And Dr. Kristina Lybecker, an associate professor at Colorado College, writes that patents not only foster pharmaceutical innovation, but also inhibit counterfeiting and fake drugs, which are widely recognized as serious barriers to access to high-quality drugs.
In recent interviews conducted by Baird’s CMC Ltd. with nine high-level Kenya public health professionals, none of them mentioned intellectual property as a key barrier to access to medicines. The two most common responses were weak health systems and cost of medicines and doctor consultations. Other reasons included late diagnosis, sub-standard drugs and a lack of health-seeking behavior on the part of the patients.
“Many times, consultancy fees are more expensive than the medicines,” said Professor Isaac Kibwage of the College of Health Sciences, University of Nairobi. “It is a bigger barrier in access to medicine.”
Similarly, in Senegal, three public health officials interviewed did not identify intellectual property as as issue but all of them identified cost of doctor visits or user fees for diagnostics.
Of 16 people active on pharmaceutical issues interviewed by Fundamento RP, a Brazilian qualitative market research consultancy, only one of them (described as an AIDS activist) identified patents as a problem. Three of them specifically said patents were not the problem.
Taila Lemos, the founder of Gentros, the Campinas Start Up, the Beta Lounge consulting innovating and Corporate Garage has a long history in the pharmaceutical field in Brazil. She said that the panel should have had more industry participation — the two Brazilians on it are very qualified, but are both from government, and the panel needs people who have actually developed medicines in the private sector.
“Here in Brazil we have people who say they are experts in Amazonia forests but they have never set foot in the Amazon,” she says. “It’s the same thing with this panel.”
She said patents are the drivers of innovation. “We developed four vaccines for animal health. It took 10 years to bring them to market. If we don’t have the protection of intellectual property, no one will invest in the development of these drugs.”
Kenya Starts to Shift Focus To Chronic Diseases While Not Relenting in HIV Fight
28th Jun 2016
By David J. Olson
For some time, huge disparities between global health spending and the global disease burden have raised concerns that this funding was not being allocated based on the evidence. That is, money was not always going where the disease burden was greatest.
The Institute for Health Metrics and Evaluation (IHME) has pointed out that the disparities are most extreme in HIV/AIDS on the high end and non-communicable diseases (NCDs) on the low end.
As the toll from communicable diseases like AIDS and malaria decline and people live long enough to get NCDs, we need to invest more in fighting NCDs (also called “chronic diseases”) and reduce these glaring disparities between global health spending and disease burden. Countries like Botswana, Eritrea, Kenya Malawi, Mozambique, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zambia — all countries that increased their treatment coverage by more than 25% between 2010 and 2015, according to UNAIDS — now have to pivot to NCDs without taking their eyes off of HIV.
Kenya is an excellent case in point. Life expectancy there peaked in 1987, and then went down in the 1990s, as AIDS made its presence felt. But as more Kenyans have gotten AIDS treatment and new infections declined, life expectancy started going up again, and is expected to return to its historic peak of 60 years in 2017, according to a World Bank blog.
That’s great news but that silver lining contains some bad news: Some people are now living long enough to get an NCD like cardiovascular and respiratory disease, diabetes and cancer.
Annually, 28 million people die from NCDs in low- and middle-income countries, representing nearly 75% of deaths from NCDs globally. Health programs, therefore, must turn their attention to this new pandemic without losing focus on the existing AIDS pandemic. And donors and governments must follow suit with funding that is in synch with the disease burden and not based on 1990s realities.
Dr. Samuel Mwenda is a seasoned soldier against both pandemics. For 13 years, as the general secretary and CEO of the Christian Health Association of Kenya, a network of Protestant church facilities in Kenya, he has led CHAK’s approach to HIV/AIDS prevention, care and treatment.
CHAK has made significant contributions to the national fight against AIDS in the four most populous provinces of the country and now supports over 41,000 clients with antiretroviral therapy, representing about 9% of the total number of patients nationally. Kenya now has the second largest treatment program in Africa (after South Africa), with nearly 900,000 people on treatment at the end of 2015.
CHAK has helped Kenya become an AIDS success story. UNAIDS says that Kenya is one of the countries “showing the most remarkable progress in expanding access to antiretroviral medicines and reducing the number of new infections.”
Several years ago, CHAK turned its attention to the emerging pandemic of NCDs, and began working on hypertension and diabetes. Seventy percent of the global cancer burden is in low- and middle-income countries like Kenya, where the probability of dying between the ages of 30 and 70 from one of the four main NCDs is 18%. NCDs account for 27% of deaths in Kenya, according to the World Health Organization.
In 2015, with the support of Novartis Access, CHAK started offering a portfolio of products to treat diabetes, hypertension, asthma and breast cancer at an end price not to exceed $1.50 per treatment per month. The program is currently in three counties of Kenya and is expected to be in all 47 counties by the end of 2017, and followed soon by Ethiopia, Rwanda and Senegal. The program hopes to be in 30 countries by 2020, depending on government and stakeholder demand.
Novartis Access calls its program a “social business,” which it expects to eventually create value, not only for society but also for Novartis.
“A key learning from HIV programs was that you cannot build awareness until there is treatment,” said Mwenda. “It’s the same with NCDs. It’s access to treatment that gets individuals and families to learn about heart disease and diabetes and to come forward for diagnosis. When people see others in their communities living long, healthy and productive lives despite NCDs, it makes them more willing to invest their own time and resources in treatment.”
“Africa is rapidly overcoming the challenges of infectious diseases,” said Mwenda. “Much of that is due to the commitment of faith-based organizations, that provide about half of all health care in the countries south of the Sahara. I believe that the same God-given mandate that we had to conquer polio and AIDS requires us to get serious about diabetes and cancer.”
On June 19, Mwenda became the third recipient of the Christian International Health Champion Award, which honors an individual who has dedicated his/her life to global health from a Christian perspective and has made significant contributions to the field and to Christian Connections for International Health (CCIH), which presented him with the award. Full disclosure: David J. Olson is a board member of CCIH.
Millions Saved Shows That Global Health Programs Can Achieve Success
24th May 2016
By David J. Olson
If you are reading this article, you probably already believe in global health, and its ability to improve the quality of life and save lives. Every month we tell some of these stories here at Global Health TV.
But some people do not believe that global health programs work or, perhaps, are just indifferent to that fact. The Kaiser Family Foundation recently released a survey of the U.S. general public that showed that the visibility of U.S. global health effort are declining – only 36% have heard a lot or some about U.S. efforts in the past year, down from 57% in 2010.
That’s why books like “Millions Saved: New Cases of Proven Success in Global Health,” written by Amanda Glassman, Miriam Temin and a team at the Center for Global Development, are so important. They provide us with specific examples of global health success that they culled from more than 300 examples of rigorous impact evaluations, and explain why they were successful.
“Around the world, people are benefiting from a global health revolution,” wrote Glassman and Rachel Silverman, both of the CGD, in a blog of the British Medical Journal (BMJ). “More infants are surviving their first months of life; more children are growing and thriving; and more adults are living longer and healthier lives. This amazing worldwide transformation begs several questions: What, specifically, are we doing right? What are the policies and programs driving the global health revolution from the ground up? Or put more simply, what works in global health, and how do we know?”
Those are the questions the authors set out to answer in this, the third version of “Millions Saved.” The first, published in 2004, provided 17 large scale global health successes. In 2007, the second edition updated the original 17 cases, and added three new ones. The 2016 version profiles 22 cases – 18 success stories and four cases of promising interventions that could not maintain success when scaled up. No one likes to talk about their failures and disappointments, but much can be learned from them.
The authors have provided us with an amazing variety of health interventions ranging from disease-specific areas like HIV, malaria, meningitis, diarrhea, polio and cancer to broader programs like neonatal, child, maternal and family health, and cash transfers, pay-for-performance and universal health care. As well as tobacco control and road safety. Africa and Asia each had seven case studies and four came from Latin America and the Caribbean.
I was disappointed that the authors could not find any successes in family planning, as the first two editions had. They addressed this in the BMJ blog:
“We are often asked about why the new Millions Saved omits a favored intervention, disease priority, or specialty. Where is mental health, for example? Or heart disease? Cancer? And what about tuberculosis or family planning? The answer is always the same: despite our best efforts, we could not find a suitable, rigorous evaluation of an at-scale program that demonstrated attributable health impact. That is not to say that interventions in these areas have not improved health at scale – it is quite likely that they have. But without rigorous at-scale evaluation, we simply cannot and do not know for sure.”
Dr. Duff Gillespie, professor at the Bill & Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, agrees there have been few well controlled intervention studies that measure the impact of family planning and suspects this will not change because donors do not see the need for such studies and because most researchers do not find such studies necessary.
“Why? There is a wealth of evidence documenting the use-effectiveness of contraceptives in preventing pregnancies. There is also tons of evidence that shows contraceptive use increases with access to family planning services. Lastly, the correlation between contraceptive use and reductions in maternal and child mortality is one of the strongest in public health. Are such correlations causal? In the case of reductions in the maternal mortality rate, absolutely. Since women must be pregnant to become a maternal death, any intervention that is effective in reducing the number of pregnancies will result in a reducing of maternal deaths. This is where contraceptive use has its biggest impact.”
Kim Longfield, director of Strategic Research and Evaluation at Population Services International (PSI), says her team did a systematic review of the effectiveness of social marketing in family planning and found a study of one program that was at scale and had significant impact – “A randomized community trial of enhanced family planning outreach in Rakai, Uganda,” which was published in Studies in Family Planning in March 2010.
The prevalence of pregnancy decreased by 3.1% in the intervention group (from 16.6% to 13.5%) and 1.3% in the control group (from 18.1% to 16.8%) between baseline and follow-up three years later. Longfield said this difference was “statistically significant.”
Longfield also said that rigorous evaluations of at-scale programs are “incredibly difficult to carry out on programs at scale. Imagine trying to have control groups at a national level.”
Steven Chapman, evidence, measurement and evaluation director of the Children’s Investment Fund Foundation in London, says that there is already ample evidence of family planning causing a decline in fertility, child mortality and maternal morbidity and mortality without trying to prove it as rigorously as is required by the “Millions Saved” case studies.
“Amanda encourages us to do a rigorous study to prove the connection but I think it is unnecessary – the health benefits of family planning are one of the many quantifiable benefits of it, and we can’t count the non-quantifiable ones.”
I hope to see this series continue into the future, perhaps with a family planning success the next time. Indeed, Glassman and Silverman end their BMJ blog with a plea: “If you care about cancer or heart disease, or tuberculosis, or family planning, please help us include it in the next “Millions Saved.”
In West Africa, More People Using Family Planning but Millions Not Treated for HIV
26th Apr 2016
By David J. Olson
BAMAKO, Mali — Last year, there were several reports of how West Africa, after decades of seriously lagging behind the rest of the world (and Africa) in family planning, was finally starting to embrace it. IntraHealth International covered this topic extensively on its Vital blog, and I wrote about my own views of family planning in Mali here at Global Health TV.
Senegal, in particular, emerged as a family planning leader in West Africa and provided hope for the rest of the region. The three main reasons for Senegal’s success were strong political will, better coordination and collaboration and innovative approaches, according to Babacar Gueye, IntraHealth country director in Senegal.
New programs here in Mali, like Keneya Jemu Kan (USAID Communications et Promotion de la Santé, in the Bambara language), are making a major push to increase health indicators beyond the anemic progress of the past three decades. For example, the percentage of married women using any modern method of family planning in Mali has only increased from 1.3% in 1987 to 9.9% in 2013, and Keneya Jemu Kan is working to bend that rate upwards. (Full disclosure: I work as a consultant for Keneya Jemu Kan).
But a disturbing new report from Médecins Sans Frontières (MSF), or Doctors Without Borders, claims that similar progress is not being made in HIV/AIDS. On the contrary, MSF claims that millions of people in West and Central Africa are being left out of the global HIV response despite globally agreed goals to curb HIV by 2020, and is calling on the international community to develop and implement an urgent plan to scale up antiretroviral treatment for countries where critical medicines reach fewer than one-third of the population in need.
The 25 countries that make up West and Central Africa account for one in five new HIV infections globally, one in four AIDS-related deaths and nearly half of all children born with HIV. MSF points out that the region has a low HIV prevalence, with 2.3% of the population infected with HIV, but that is three times the worldwide prevalence of 0.8%, and pockets of the region have prevalence over 5%.
HIV prevalence in West and Central Africa is lower than Eastern and Southern Africa. This lower prevalence has led to “poor knowledge of the disease among the general population, political leaders and health workers” and less funding by international donors.
“The converging trend of international agencies to focus on high-burden countries and HIV hotspots in sub-Saharan Africa risks overlooking the importance of closing the treatment gap in regions with low antiretroviral coverage, said Dr. Eric Goemaere, MSF’s HIV referent. “The continuous neglect of the region is a tragic, strategic mistake. Leaving the virus unchecked to do its deadly work in West and Central Africa jeopardizes the goal of curbing HIV/AIDS worldwide.”
Pape Gaye, president and CEO of IntraHealth and a native of Senegal, says that the problems cited by MSF are another example of why the international community needs to mobilize to help countries strengthen their health systems.
“The difficulties experienced by Ebola-affected countries to address the disease and the inabilities of countries to protect and sustain gains, including recent ones in family planning and reproductive health, point to the need for more attention to health systems strengthening,” said Gaye. “The region of West and Central Africa is poised to enter a new era of growth and prosperity but the momentum will dramatically slow down or vanish unless coordinated effort is made to rid the region of HIV/AIDS. This is not the time to continue erratic and fragmented interventions which produce results such as those described in the MSF report.”
The Ouagadougou Partnership, an initiative of nine French-speaking West African countries to promote family planning started in 2011, set a goal of reaching one million new family planning users in these nine historically under-performing countries by 2015. At their annual meeting in December 2015, members of the Partnership celebrated the achievement of this goal.
MSF is now calling for the same kind of urgent call to arms to address HIV/AIDS and a plan to achieve progress, much as the Ouagadougou Partnership did to address family planning. If we can do it for family planning, we should be able to do it for HIV/AIDS and thereby ensure that West and Central Africa do not thwart our efforts to achieve an AIDS-free generation.
Diarrhea Deaths Are Falling But ORS Use Still Stagnant
26th Oct 2015
By David J. Olson
I’m grateful to Chelsea Clinton for her admission that she is “obsessed with diarrhea,” and her total lack of embarrassment in bringing it up repeatedly. In an interview with Fast Company, it was the first thing she wanted to talk about.
I’m grateful to her because she is, as far, as I know, the only well-known public figure to champion the prevention and treatment of diarrhea, the world’s second biggest killer of children under five years old, even though we have cheap and effective ways of dealing with it.
“It’s completely unacceptable that more than 750,000 children die every year because of severe dehydration due to diarrhea,” said Clinton last year. “I just think that’s unconscionable.”
We need more champions of the diarrhea issue.
Four years ago, I wrote a blog bemoaning the fact that oral rehydration therapy (ORT) seemed to be on life support, even though The Lancet once called it “the most important medical advance of the 20th century.” ORT and its practical application, oral rehydration solution (ORS), have long been found to be both effective and cost-effective in treating the dehydration caused by diarrhea.
Bangladesh is perhaps the best example of a country that has made stellar progress in fighting diarrhea through ORS. The treatment of diarrhea increased from 58% in 1993 to 81% in 2011. Productive collaborations between the government, the private sector and organizations like the Social Marketing Company, which used social marketing revenues to build an ORS factory in Bangladesh in 2004, have led to tremendous improvements in diarrhea disease management.
Starting in the 1970s, ORS has saved an estimated 50 million lives, costing less than $0.30 per sachet, according to the WHO. In 1978, the World Health Organization (WHO) established the Control of Diarrheal Diseases Program, and by the early 1980s, most developing countries had their own dedicated national programs.
But even though ORS was cheap and effective, the global health community moved on to other diseases, like AIDS and malaria. In the 1990s, these diarrheal disease programs were merged into broader child health programming, and lost their dedicated funding, staff, and systems. A 2008 analysis that looked at changes in ORS use in children under three found declines in 23 countries and increases in only 11.
A 2009 research study conducted by PATH, a leading NGO working to fight diarrhea, to evaluate the funding and policy landscape found that “diarrheal disease ranked last among a list of other global health issues.”
After years of neglect, diarrhea is back on the global health map. Diarrhea deaths among children under five are down from 700,000 per year in 2011 to around 531,000 in 2015, according to PATH, a drop of 24% in four years. The bad news is that ORS use has stagnated, says PATH, at around 35% over the last 10-15 years.
Why has diarrhea death dropped even though ORS has stagnated?
“It’s been because of increasing access to a set of protection, prevention and treatment interventions,” said Ashley Latimer, senior policy and advocacy officer at PATH. “More children are being vaccinated against rotavirus (a leading cause of diarrhea). Understanding the importance of hand-washing and clean drinking water is improving. Improved nutrition and exclusive breastfeeding probably plays a small role.”
In 2013, the WHO and UNICEF published “Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025,” the first-ever global plan to tackle the two diseases that take the lives of 2 million children every year, which was supported by more than 100 nongovernmental organizations.
There are several efforts underway to fight diarrhea more effectively.
For example, PATH is working to improve the formulation of ORS to make its benefits more apparent to caregivers.
“Reimagining global health” recently highlighted “30 high-impact innovations to save lives.” One of them (see Page 17) included several new treatments to reduce the burden of severe diarrhea, such as DiaResQ, which supplements the use of ORS and provides nutrients for intestinal repair.
An already established innovation is to create “comprehensive diarrhea treatment” by combining zinc with ORS. Zinc is a vital micronutrient that helps the body absorb water and electrolytes, reduces the duration and severity of diarrhea and prevents subsequent infections in the two to three months following treatment. Diarrhea mortality is reduced by 23% when zinc is administered with ORS. Unfortunately, use of zinc is even worse than ORS – only 5% as compared to 35% for ORS.
Diarrheal disease research and development funding is increasing modestly. In 2013, it was $200 million, up from $170 million in 2012. As in previous years, the top three funders accounted for almost three-quarters of total funding – the Bill & Melinda Gates Foundation (25% of funding), the U.S. National Institutes of Health (23%) and industry (22%).
“With the introduction of rotavirus vaccines and advances in WASH interventions, these are exciting times,” said Deborah Kidd, senior communications officer at PATH. “However, what is often overlooked is the burden of diarrhea morbidity among children in the developing world. Chronic, repeated infections, resulting malnutrition and stunted development, and the persistent economic burden on the family all contribute to a destructive cycle that keeps families in poverty. So it’s great news that deaths are declining, but that the problem of childhood diarrhea and its long-term consequences are far from solved.”
UNICEF reports that improvements in drinking water, sanitation and hygiene are reducing diarrheal disease (90% of the world’s population use improved drinking water sources and two-thirds use improve sanitation facilities).
However, the decline in diarrhea deaths should be no cause for complacency: UNICEF also reports that when children do fall ill with diarrhea, only two in five children receive appropriate treatment, including ORS.
Unlike many diseases, for which no cure exists, the cure for diarrhea has been around for decades and is cheap and available. We just have to find the financial, technical and social means to get it to people who need it, and help them use it to protect the health of their families.
This infographic shows the status of the war against pneumonia and diarrhea in the world’s poorest children.